Conventional Hernia Repair Research Articles

Selective anterior annuloplasty during inguinal herniotomy in boys: an approach to further reduce hernia recurrence.

Hernia recurrence is one of the most common complications after inguinal herniotomy (IH) in children. We describe a novel approach that involves adding anterior annuloplasty (AAP) during IH for selective high recurrence-risk children. Evaluate the initial safety and effectiveness of selective AAP during IH in boys. Retrospective SETTING: Tertiary care center. The study included boys younger than 15 who were selected to undergo either IH with or without AAP between January 2011 and January 2022. The preoperative recurrence risks were compared for the two groups. Cases who underwent other forms of hernia repair were excluded. The frequency of recurrence and other postoperative complications and the distribution of high recurrence-risks. 315 boys; 143 underwent IH and AAP, while 172 had IH only. Among all the cases, only one recurrence was reported (0.3%). Other complications were hydrocele in 29 (9.2%), scrotal hematoma/inflammation in 9 (2.9%), and wound infection in 8 (2.6%), which resolved spontaneously in all cases. Compared to IH only, those selected for an additional AAP were significantly younger (3 [16%] vs. 12 [46%] months, P=.038) and more likely to be premature (35 [24.5%] vs. 15 [8.7%], P<.0001), frequently had extensive cremasteric adhesions (39.2% versus 3.5%, P<.0001) and had a higher rate of incarcerated hernia at presentation (6.3% versus 1.2%, P=.026). The high-recurrence risk group was almost twice as likely to be selected for an additional AAP compared to the low-risk group (143 vs. 75, P<.0001). Adding simple AAP to conventional hernia repair for high-recurrence risk boys can be a safe and effective step to reduce the overall risk of recurrence without increasing the incidence of other postoperative complications. The study lacked a control group of patients to whom selective AAP would not be offered despite a high-recurrence risk. A prospective, controlled trial with a longer follow-up would lead to a stronger conclusion.

English

BACKGROUND Aim of the surgeon repairing the ventral hernia is to alleviate the symptoms and prevent complications with minimal recurrence rates. Recent times have seen the popularity of laparoscopic approach but there is reasonable controversy to its optimal approach when compared to conventional method. The present study analyses and correlates the postoperative outcomes of patients who underwent laparoscopic and conventional methods of ventral hernia repair during the last three years. METHODS This is a cross-sectional clinical study in which 87 patients diagnosed with ventral hernia from the Department of General Surgery of Government Medical College and Hospital, Nizamabad from September 2017 to August 2020 were included. 42 patients underwent laparoscopic repair and 45 underwent conventional hernia repair. Patients aged between 35 and 74 years belonging to American Society of Anaesthesiologist (ASA) grade I and II were included. Clinical history, surgical profile and anaesthesia fitness were obtained using standard operating procedures. All patients were followed up to 06 months. Data variables such as age, gender, BMI (Body Mass Index) size of defect, postoperative hospital stay and other complications were collected and analysed. RESULTS Out of 87 patients, laparoscopic group had 27 (59.52 %) females and 15 (35.71 %) males with a female to male ratio of 1.8:1. Whereas conventional hernia repair group had 29 (64.44 %) females and 16 (35.55 %) males with a female to male ratio of 2:1. 38 out of 87 (43.67 %) patients were in the age group of 45 to 54 years. Incisional hernia - infra umbilical type was found in 34 out of 87 (39.08 %) patients while incisional hernia - supra umbilical type was found in 23 out of 87 (26.43 %) patients. Correlating the adverse events between laparoscopic method and conventional methods of ventral hernia repair showed a statistical significance. Pearson correlation coefficient was with R factor of 0.983 and the P value was 0.00001 (P significant at &lt; 0.05) CONCLUSIONS Laparoscopic ventral hernia repair (LVHR) using bio-material mesh for the repair resulted in low postoperative pain, wound infection, graft rejection and higher long-term recurrence free patient satisfaction when compared to conventional hernia repair. KEYWORDS Ventral Hernia, Anterior Abdominal Wall, Laparoscopy, Repair and Recurrences

Inguinal Hernia: Defect Obliteration with the 3D Dynamic Regenerative Scaffold Proflor™

Prosthetic inguinal hernia repair presents significant challenges. Some of these, such as mesh fixation and quality of the biologic response, are still debated among surgeons. For example, there is no strong consensus regarding a specific condition that characterizes the surgical procedure during herniorrhaphy. This issue concerns management of the hernia defect, which in conventional hernia repair with flat meshes remains patent. However, a critical analysis of typical postoperative complications after inguinal hernia repair reveals that some of these adverse events are related to patency of the hernial opening. Postoperative discomfort, pain with specific movements and even hernia recurrence can be caused by incomplete or defective management of the hernia defect. For this reason, a deeper understanding of this topic would be useful for improving postoperative outcomes. A recently updated concept for inguinal hernia repair takes this technical aspect into consideration. It is based on the use of a newly developed 3D scaffold—ProFlor™ (Insightra Medical, Inc., Clarksville, TN, USA)—that is intended to be deployed into the defect. This novel hernia repair device has interesting and original features, such as dynamic responsivity in compliance with inguinal movement, fixation-free mode and regenerative behavior that counteracts the degenerative effects of the disease. Another additional proprietary feature of this 3D scaffold is the full and permanent obliteration of the defect, which is a crucial aspect to improve outcomes by avoiding the typical adverse effects of this surgical procedure. Obliteration of the hernia defect with the 3D dynamic regenerative scaffold ProFlor™ appears to be superior to coverage by means of static (passive) flat meshes/plugs used in conventional hernia repair. This report highlights the principles of this procedural approach.

PEDİATRİK YAŞTA AMYAND HERNİ: TEK CERRAH DENEYİMİ

Objective Amyand's hernia is the presence of appendix in the hernia sac and is rarely seen. The diagnosis is mostly made incidentally during the operation performed due to the incarcerated inguinal hernia. It was aimed to present the experience about this rare pathology. Material and Method Analysis of 10 children with Amyand's hernia operated by a single pediatric surgeon between 2011 and 2017 was performed, retrospectively. Demographic features (age, gender), complaints, treatment methods, histopathological findings and postoperative results were evaluated. Results All patients were male. The average age was 12.02 months (17 days-8 years). All had a right inguinal hernia. Emergency surgery was performed in 4 of the patients with an initial diagnosis of incarcerated inguinal hernia. The remaining 6 patients were diagnosed incidentally during elective hernioplasty. While 9 patients were treated with conventional hernia repair, only one patient underwent laparoscopy. Surgical findings included 7 normal appendices ve 3 inflamed appendices. Of 3 patients with appendix adhered to the hernia sac, 2 has appendicitis and 1 has lymphoid hyperplasia. Appendectomy was performed during inguinal hernia repair in 4 patients and hernia repair was performed in 6 patients without appendectomy. Recurrent hernias were not observed in any patients. Conclusion Amyand's hernia should be kept in mind in the differential diagnosis of patients with right inguinal hernia. The inflammation status of appendix adhering to the hernia sac should be carefully evaluated for an appropriate treatment decision.

Effects of insistent screening for contralateral patent processus vaginalis in laparoscopic percutaneous extraperitoneal closure to prevent metachronous contralateral onset of pediatric inguinal hernia.

Laparoscopic percutaneous extraperitoneal closure (LPEC) is known to reduce the incidence of metachronous contralateral hernia (MCH) compared to conventional hernia repair. We herein describe the effects of insistent screening for an irregular orifice of the contralateral patent processus vaginalis (CPPV). All patients who underwent LPEC between 2003 and 2013 were reviewed. We started insistent screening for a CPPV in July 2010. The surgically treated cases before June 2010 were assigned to the former group, while those treated after July 2010 were in the latter group. The data were retrospectively collected from medical records. The statistical analysis was performed using the Mann-Whitney U test or Chi square test. A value of P<0.05 was considered to be significant. A total of 1113 patients (514 males and 599 females) ranging in age from 3months old to 15years old (median 4.6years old), were reviewed. Of the 626 patients in the former group, a CPPV was detected in 227 patients. Of the 487 patients in the latter group, a CPPV was detected in 271 patients. The incidence of a CPPV significantly increased over time (P<0.001). We encountered five cases of MCH, all of which belonged to the former group (P=0.048). The increased detection of a CPPV by insistent screening seemed to cause a decrease in the incidence of MCH.

Quality of Life after Ventral Hernia Repair with Endoscopic Component Separation Technique.

Large ventral hernias are often associated with physical, social, and health problems for the patient, and surgical repair remains a challenge. Open components separation has widely been applied to obtain closure of the midline and recently a minimally invasive technique has been introduced (endoscopic components separation). The effectiveness and safety of endoscopic components separation have been demonstrated in previous reports, whereas little is known about quality of life in these patients. With a focus on quality of life, we present the first patients from our center operated on with endoscopic components separation. A total of 19 consecutive patients scheduled for open hernia repair with endoscopic components separation from October 2010 to June 2012 were included. All procedures included endoscopic components separation because of the hernia size. Demographic data, operative information, and postoperative complications were recorded. All patients completed two similar questionnaires regarding their function level, cosmetic satisfaction, analgesic medication, alcohol consumption, and self-estimated physical and mental health before and after the hernia repair. Patients were assessed as outpatient median 2 months and 16 months after operation for exclusion of hernia recurrence and completion of the postoperative questionnaire. Operating room time was median 204 min and correlated significantly with the hernia size. A total of 21 postoperative complications occurred in 14 patients. The length of stay was median 6 days and correlated significantly with duration of the operation. Of these, 15 patients participated in late follow-up visit. Two patients experienced recurrent hernias. Postoperative function level, cosmetic satisfaction, and self-estimated physical and mental health improved significantly. Alcohol consumption was significantly reduced. Endoscopic components separation is a reliable method to repair large ventral hernias, although further studies are required to determine the exact benefits for endoscopic components separation hernia repair versus conventional hernia repair.

Elective laparoscopic surgery for sigmoid colon carcinoma incarcerated within an inguinal hernia: report of a case

Primary colon carcinoma within an inguinal hernia sac is very rare and most reported cases were found at emergency open surgery for an incarcerated hernia. We report a case of incarcerated sigmoid colon carcinoma diagnosed preoperatively and treated with elective laparoscopic surgery. A 67-year-old man with a 2-year history of swelling of the scrotum and a breast lump was referred to us for surgical treatment of an irreducible left inguinal hernia and a right breast tumor. Blood examination results showed severe anemia. Computed tomography scan and endoscopic biopsy confirmed sigmoid colon carcinoma incarcerated in the left inguinal hernia. Thus, we performed definitive laparoscopic sigmoidectomy and conventional hernia repair for preoperatively diagnosed sigmoid colon carcinoma within an inguinal hernia.

Association between abdominal separation and inguinal or crural hernias: Our experience and surgical indications

Abdominal wall weaknesses present several causative factors, both local and systemic and, as a consequence, abdominal hernias may develop in more than one site. Also, simultaneous hernia repair has been rarely reported in published reports. In the present study, the association of multiple weaknesses of the abdominal wall in patients undergoing conventional abdominoplasty or hernia repair were evaluated, and the advantages of simultaneous repair in a single operation are discussed. In a 3-year time period, all patients undergoing abdominoplasty or abdominal hernia repair were clinically and instrumentally evaluated for the association between median abdominal wall weakness and inguinal and/or crural hernias. The body mass index (BMI) was also considered and photographic documentation was taken before the operation and during the follow-up. When this association was confirmed, patients underwent contemporary correction of both conditions using an abdominoplasty approach. The presence of inguinal and/or crural hernias was observed in 10% of all patients undergoing conventional abdominoplasty and in 14.5% of patients with laparocele in the institution. The BMI was higher in patients with the association than in those without. Good aesthetic and functional results were achieved and the complication rate was low. The role of obesity as a triggering factor of abdominal wall weaknesses is confirmed by the higher BMI in patients with associated diseases. These observations remark the fact that the association between median abdominal wall weakness and inguinal or crural hernias should always be investigated. If this association is confirmed, it is preferable to treat both conditions simultaneously.

Lichtenstein’s mesh versus Bassini tissue repair technique for obstructed inguinal hernia: a controlled randomized study

The purpose of the study is to evaluate the use of synthetic mesh in obstructed inguinal hernia. Synthetic mesh repairs in inguinal hernia, though gold standard in elective operation is controversial in emergency setting. With an obstructed/strangulated hernia being the usual presentation, infection is the main concern. However, recent data indicated that mesh has advantages in emergency settings also. We took up a prospective study to evaluate this. Prospective randomized controlled single-blinded study with 20 patients in each group. One group had modified Bassini tissue repair and the other Lichtenstein repair with polypropylene mesh. Statistical analysis: the t-student/Fisher test and chi-square tests. Follow-up period: 2-years. Operating time and postoperative hospital stay was significantly less in mesh repair. Mesh repair showed an edge over pure tissue repair. Wound infection, seroma formation, and neuralgia were less in mesh repair with the difference in seroma formation being significant. Tension-free hernioplasty using polypropylene mesh in adults with obstructed inguinal hernia should be preferred to conventional hernia (pure tissue) repair, especially where there is no resection anastomosis/perforation. The conclusion is limited to the analyzed patients and long-term analysis in a larger study population is indicated.

Laparoscopic Incisional Hernia Repair After Solid-Organ Transplantation

Background Incisional hernias are a frequent problem after liver transplantation. Mesh repair techniques including laparoscopic repair have been employed in order to address this problem. We have introduced intraperitoneal onlay mesh repair (IPOM) in 2008 because of advantages that had been reported in the literature. To perform a structured comparison of methods and outcomes, we compared patients who have been treated with IPOM and those who have been treated conventionally. Methods We included 29 consecutive patients (15 IPOM, 14 conventional hernia repair [CHR] who have been analyzed and have been examined clinically and sonographically during their follow-up. Results Recurrence rate was 6% (IPOM) and 50% (CHR), complication rate was 33% (IPOM) and 21% (CHR), mean hospital stay was 7.2 (IPOM) and 9.7 (CHR) days. None of the 29 patients had an impaired wound healing or infectious complications. Of the 29 patients, 10 received sirolimus for immunosuppression, which was switched preoperatively to a calcineurin inhibitor. Conclusion IPOM results in a shorter hospital stay. The complication rate with IPOM was higher compared with CHR, recurrence rate was considerably lower. The role of perioperative sirolimus switch needs to be interpreted with caution, but should be further investigated because of potential advantages with respect to fewer wound healing complications.

Small Bowel Obstruction Caused by an Incarcerated Hernia after Iliac Crest Bone Harvest

The iliac crest has become an often used site for autogenous bone graft, because of the easy access it affords. One of the less common complications that can occur after removal is a graft-site hernia. It was first reported in 1945 (see the work by Oldfield, 1945). We report a case of iliac crest bone hernia in a 53-year-old male who was admitted for elective resection of a pseudarthrosis and reconstruction of the left femur with iliac crest bone from the right side. One and a half months after initial surgery, the patient presented with increasing abdominal pain and signs of bowel obstruction. A CT scan of the abdominal cavity showed an obstruction of the small bowel caused by the bone defect of the right iliac crest. A laparoscopy showed a herniation of the small bowel. Due to collateral vessels of the peritoneum caused by portal hypertension, an IPOM (intraperitoneal onlay-mesh) occlusion could not be performed. We performed a conventional ventral hernia repair with an onlay mesh. The recovery was uneventful.

Konventionelle Reparation der parastomalen Hernie

The reparation of parastomal hernias and their recurrence remain problematic although the implementation of mesh techniques has lowered recurrences rates. Conventional surgical techniques include suture repair, relocation of the stoma as well as diverse hernia repair procedures with mesh implantation. Suture repair has been abandoned due to its high recurrence rate. Simple relocation is not recommended because of high rates of recurrent parastomal hernias. Conventional hernia repair using mesh implants is classified according to the mesh position into epifascial (onlay), retromuscular (sublay) and intraperitoneal (IPOM) techniques. Furthermore, a combination of relocation with additional mesh enforcement is also possible. The value of the different mesh techniques and of new biological mesh prostheses must be evaluated in randomized controlled studies.

Chronic Groin Pain Following Lichtenstein Mesh Hernioplasty for Inguinal Hernia. Is It a Myth, How True is It?

Going through the article titled “chronic groin pain following Lichtenstein mesh hernioplasty for inguinal hernia. Is it a myth?”, was a treat to read that such an important aspect of a routine surgery has been addressed to, which usually is forgotten in this very common surgical procedure. It is good to see such an astonishing amount of cases being performed i.e. 470 cases which almost reaches to two cases per day considering only <300 working days a year in Indian scenario which is land of festivals. We wanted to clarify that in the material and methods it has been mentioned that patients were followed up at 3 months, 6 month, 1 year and 2 year after surgery. Since the study period was from 01 Feb. 2006 to 29 Feb. 2008 which constitutes only two years, then how is it possible that many patients reached the end point described in material and method. Even if we consider the date of paper submission as last date of study i.e. November 2008 only those cases which were operated before November 2006 would have been followed up for 2 years postoperatively , which would amount to almost one third of the total patients only. Why we are stressing on this is that the frequency of chronic groin pain reported by the author of 0.78% is extremely low compared to range of 0% to 37% of patients undergoing conventional hernia repair [1]. Johann Cunningham et al noted 12% incidence of moderate or severe pain one year after open hernia surgery [2]. Having said that, there are also series which have reported very low rates as well. Sergio Alfieri et al observed chronic severe pain in only 0.5% of patients at 1-year follow-up [3]. This is paramount in saying that if there is such a low incidence of chronic groin pain with polypropylene mesh than where is the need for all the light weight meshes which are being propagated. This low rate reported is tremendous in that we should recommend the technique of surgery which has been used by the author and should standardize the procedure Electronic supplementary material The online version of this article (doi:10.1007/s12262-010-0147-8) contains supplementary material, which is available to authorized users.

Groin hernia repair in young males: mesh or sutured repair?

Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available. We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair. Prospective recording of all inguinal hernia repairs from 1 January 1998 to 31 December 2005 in the national Danish Hernia Database, using reoperation rate as a proxy for recurrence. We included only men between the age of 18 and 30 years with a primary repair of a primary indirect inguinal hernia. A primary sutured repair was performed in 1,120 men (median age 23 years, range 18-30) and a Lichtenstein mesh repair in 2,061 young men (24 years, range 18-30) (total 3,181 patients). The observation time after conventional hernia repair was median 62 months (range 0-96) and 41 months (range 0-96) after a Lichtenstein repair. The cumulative incidence of reoperation at 5 years was 1.6% (Lichtenstein) versus 3.9% (sutured repair), while overall reoperation rates were almost three-fold as high after a sutured repair (39 reoperations, overall reoperation rate = 3.5%) compared to a Lichtenstein repair (24 reoperations, overall reoperation rate = 1.2%; P = 0.0003). Lichtenstein repair for an indirect inguinal hernia reduces the risk of recurrence in young men between the age of 18 and 30 years compared with a sutured repair. The use of a Lichtenstein mesh repair in young males must be balanced against the risk of chronic pain.

Commentary on: T. Sinnett, N. Karanjia (2009) Decompression of a pneumoperitoneum during a total extraperitoneal (TEP) inguinal hernia repair by incision of the umbilical sac under direct vision

Since total extraperitoneal (TEP) hernia repair was introduced in the early 1990s, there has been associated discussion regarding pneumoperitoneum. If the latter occurs, and this is not a rare event, the extraperitoneal space can become smaller. This can of course seriously interfere with the TEP procedure and in some cases can necessitate conversion to transabdominal preperitoneal (TAPP) or conventional hernia repair, especially in the early stages of the learning curve. As a solution to this problem many surgeons use a Verres needle for decompression of the peritoneal space. As Sinnett mentions in his letter to the editor, this method encompasses all the disadvantages and risks of blind peritoneal puncture. In addition, a Verres needle has a maximum flow rate of 2 l/min. So decompression takes time, or is impossible or unsatisfactory due to the much higher flow rate of any working trocar. Thus, according to in our experience, following a few unsuccessful attempts in 1994, we have never considered a Verres needle as the solution to the problems of pneumoperitoneum. Sinnett now mentions a new method of decompression by umbilical opening of the peritoneal sac. This of course seems to be safe, and probably gives rise to a better flow. However, due to surface tension, the smaller bubble (extraperitoneal space) will always blow up the bigger one (intraperitoneal space). Thus, in my mind, and in our experience, decompression of the intraperitoneal space does not provide a routine solution to the problem of peritoneal tears in TEP (in our hands close to 50% of procedures). We use a different procedure and, since we started with TEP, up to now we have never had a conversion due to pneumoperitoneum in more than 8,000 cases in two different clinics:

(222) Treatment of Genitofemoral Neuralgia After Laparoscopic Inguinal Herniorrhaphy with Fluoroscopically-Guided Tack Injection

Nerve entrapment syndromes involving the genital branch of the genitofemoral nerve, the ilioinguinal nerve, or the iliohypogastric nerve occur in an estimated 1–2% of conventional, open herniorrhaphies [3], and can also occur with laparoscopic herniorrhaphies [1]. A 48-year-old man with a recurrent right-sided inguinal hernia underwent a laparoscopic hernia repair using Prolene mesh and titanium tacks. Two weeks post-operatively, the patient spontaneously developed severe, intermittent, lancinating pain in a genitofemoral nerve distribution. Infection and recurrent hernia were ruled out. Treatment with non-steroidal anti-inflammatory drugs, muscle relaxants and ilioinguinal nerve blocks using traditional anatomic landmarks were unsuccessful. A focal point of tenderness at the inferolateral portion of the pubic ramus was investigated under fluoroscopy and was found to be directly overlying a surgical tack. Palpation over this site produced a Tinel's sign reproducing the patient's pain. A diagnostic injection using local anesthetic was performed at this site. The patient was pain-free for two months following the injection. When the pain returned, the injection was repeated using local anesthetic with corticosteroid, using the same fluoroscopically-guided technique. The patient has been asymptomatic since that time. Laparoscopic hernia repair may pose increased risk of nerve injury than conventional hernia repair [1]. With a conventional repair the nerves at risk are generally visible and may be dissected free, thus avoiding nerve injury. In contrast, with the laparoscopic repair the staples are placed preperitoneally and the nerves cannot be visualized. In a patient with suspected nerve entrapment syndrome following laparoscopic hernia repair, injection therapy may be effective treatment. As illustrated in this paper, fluoroscopy can be useful during physical exam and as an aid in localizing and for performing the injection. If an injection offers significant but transient relief, surgical removal of the staple or neurectomy at a site proximal to the lesion may be indicated [2].

Open versus laparoscopic incisional hernia repair: something different from a meta-analysis

Incisional hernias after laparotomy are a large financial burden for society as well as for the patients suffering from pain and limitations of activity over time. The introduction of alloplastic materials such as polypropylene seems to improve the results. The question of whether to apply open or laparoscopic implantation of the mesh is of ongoing interest. We compare the available alloplastic materials and try to clarify the question of whether the laparoscopic procedure is superior to the conventional (open) technique based on the available randomized studies. All available meshes for intraperitoneal and extraperitoneal implantation were described regarding their handling and their pros and cons. A database search (PubMed, Medline, Ovid, and in the secondary literature) was carried out to retrieve all randomized studies comparing laparoscopic and open hernia repair. Data were reviewed by two independent scientists for surgical and statistical design. The ideal mesh for a laparoscopic maintenance of abdominal wall hernias as well as the optimal fixation of the mesh has not been found yet. Recent available literature shows no evidence demonstrating the superiority of one of these meshes. The available studies found a lower infection rate, but higher occurrence of seroma for the laparoscopic procedure. The value of the different studies is reduced due to deficiency in study design and power. Guidelines for further studies are discussed to avoid surgical and statistical pitfalls. Laparoscopic incisional hernia repair shows, in some (randomized) studies as well as a large number of retrospective analyses and in case control studies, superiority compared to conventional hernia repair. Long-term results with a high level of evidence are not available. Additional well-designed randomized trials including long-term observation of patients are required in order to clarify a number of interesting questions.

Occult hernias and bilateral endoscopic total extraperitoneal inguinal hernia repair: is there a need for prophylactic repair?

An advantage of the endoscopic total extraperitoneal approach over the conventional hernia repair is detection of an unsuspected, asymptomatic hernia on the contralateral side. A high incidence of occult contralateral hernias has been reported in the literature. However, few studies have examined the incidence of development of a hernia on the healthy side evaluated previously during an endoscopic unilateral hernia repair. This study aims to evaluate the incidence of development of a contralateral hernia after a previous bilateral exploration. The need for a prophylactic contralateral repair is also addressed. We retrospectively reviewed the results of 822 endoscopic total extraperitoneal inguinal hernia repairs done in 634 patients over a period of 10 years from May 1993 to 2003. Incidence of hernia undetected clinically and during previous contralateral repair was assessed over a follow up period ranging from 10 to 82 months. About 7.97% of bilateral hernias were clinically occult hernias. Only 1.12% of unilateral hernia repairs (who had undergone a contralateral evaluation at surgery) subsequently developed a hernia on the other side. The endoscopic approach to inguinal hernia repair is an excellent tool to detect and treat occult contralateral hernias. The incidence of hernia occurring at the contralateral side after a previous bilateral exploration is low, hence a prophylactic repair on the contralateral side is not recommended on a routine basis.

Stellenwert der endoskopischen Chirurgie von Leistenhernien

The endoscopic techniques of groin hernia repair have developed tremendously over the past 10 years. There are numerous prospective randomized clinical trials comparing conventional techniques of groin hernia repair with endoscopic methods. However, it is difficult to establish a proper meta-analysis of the currently available data due to widely differing study designs. We assessed the currently available prospective randomized clinical trials comparing conventional versus laparoscopic hernia repair. We conclude that based on present data there is a clear advantage for the endoscopic techniques regarding length of hospital stay, postoperative recovery and return to normal activity. The conventional techniques are superior regarding duration of operation and direct cost. Rate of recurrence are comparable in both, endoscopic and conventional approach using mesh prosthesis. Endoscopic techniques are far superior to conventional operation without the use of mesh prosthesis. In patients with recurrent hernia endoscopy offers a major advantage regarding postoperative pain, lenght of hospital stay, return to normal activity and rate of recurrence. We demonstrate these suggestions discussing our own results. Therefore we recomend endoscopic hernia repair in patients with bilateral or recurrent hernia.

The Effects of Intraabdominally Insufflated Carbon Dioxide on Hepatic Blood Flow During Laparoscopic Surgery Assessed by Transesophageal Echocardiography

Conflicting results have been published about the effects of carbon dioxide (CO(2)) pneumoperitoneum on splanchnic and liver perfusion. Several experimental studies described a pressure-related reduction in hepatic blood flow, whereas other investigators reported an increase as long as the intraabdominal pressure (IAP) remained less than 16 mm Hg. Our goal in the present study was to investigate the effects of insufflated CO(2) on hepatic blood flow during laparoscopic surgery in healthy adults. Blood flow in the right and middle hepatic veins was assessed in 24 patients undergoing laparoscopic surgery by use of transesophageal Doppler echocardiography. Hepatic venous blood flow was recorded before and after 5, 10, 20, 30, and 40 min of pneumoperitoneum, as well as 1 and 5 min after deflation. Twelve patients undergoing conventional hernia repair served as the control group. The induction of pneumoperitoneum produced a significant increase in blood flow of the right and middle hepatic veins. Five minutes after insufflation of CO(2) the median right hepatic blood flow index increased from 196 mL/min/m(2) (95% confidence interval (CI), 140-261 mL/min/m(2)) to 392 mL/min/m(2) (CI, 263-551 mL/min/m(2)) (P < 0.05) and persisted during maintenance of pneumoperitoneum. In the middle hepatic vein the blood flow index increased from 105 mL/min/m(2) (CI, 71-136 mL/min/m(2)) to 159 mL/min/m(2) (CI, 103-236 mL/min/m(2)) 20 min after insufflation of CO(2). After deflation blood flow returned to baseline values in both hepatic veins. Conversely, in the control group hepatic blood flow remained unchanged over the entire study period. We conclude that induction of CO(2) pneumoperitoneum with an IAP of 12 mm Hg is associated with an increase in hepatic perfusion in healthy adults.