Inguinal Hernia Repair Surgery Research Articles

NEW TECHNOLOGIES AT THE SERVICE OF THE PATIENT

Abstract Introduction In the surgical field, information about operations is traditionally written down in the informed consent form, which often uses technical language that is difficult for patients to understand. Even when accompanied by verbal explanations, patients only seem to retain between 20–60% of the details. With the purpose of improving the effectiveness of communication with our patients during the surgical process, from the Day Surgery Unit of our hospital we have developed a protocol to provide an audio-visual aid to the information supplied. Methods Two explanatory videos were developed for inguinal hernia repair and pilonidal cyst surgery, which were given to the patients under the care of our service using a QR code, both in the preoperative consultation and at discharge. The videos included simple explanations regarding the disease, procedure and postoperative care, in terms easily understandable to the general population. Subsequently, during postoperative follow-ups, feedback from the first 105 patients was collected. Results Results showed that, out of the first 105 patients who received the QR code, 72 watched the video, and of those, 100% were satisfied with the quality of the information provided and recognised that it improved their understanding of the procedure. Conclusions The use of new technologies, and, more specifically, of audio-visual support, could help to improve the comprehension of information received throughout surgical procedures, since it enables its repeated viewing and its sharing with relatives, which could improve the patient's overall satisfaction.

EFFECT OF ADDITION OF DEXAMETHASONE TO LEVOBUPIVACAINE ON POST-OPERATIVE ANALGESIA IN ULTRASONOGRAPHY-GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCK FOR INGUINAL HERNIA REPAIR: A PROSPECTIVE RANDOMIZED COMPARATIVE STUDY

NTRODUCTION- Postoperative pain is literally a form of acute pain which follows surgical insult with an inammatory reaction and initiation of an afferent neuronal signal bombardment. Due to inadequate management of postoperative pain many patients continue to suffer unnecessarily. Hence it is understood that managing the post operative pain effectively is the need of the hour to reduce postoperative morbidity. AIMS - To evaluate and compare the duration of sensory blockade of 0.25% levobupivacaine with and without dexamethasone in ultrasonography-guided transversus abdominis plane(TAP) block. METHODS-After obtaining approval from Institutional ethical committee, a prospective randomized comparative study was carried out in 60 patients of ASA Grade I & II undergoing inguinal hernia repair under spinal anaesthesia. Patients were randomly divided into 2 groups; Group L(n=30) received 30ml of 0.25% Levobupivacaine with 2ml of Normal saline (NS) while Group D (n=30) received 30ml of 0.25% Levobupivacaine with 8mg Dexamethasone. RESULTS- Patients in group D (8.07±1.34 hr) had prolonged duration of analgesia in comparison to group L (5.33±1.92 hr) (p= 0.000). CONCLUSION- In the inguinal hernia repair surgeries performed under spinal anaesthesia with ultrasonography-guided TAP block, addition of dexamethasone was superior to levobupivacaine alone in providing better and prolonged post-operative analgesia with minimal post-operative nausea and vomiting

Bronchoscopic Guided Intubation through Laryngeal Mask Airway in a Patient with Ankylosing Spondylitis

Patients with ankylosing spondylitis present with airway difficulties. There are various techniques to secure a definitive airway for general anaesthesia in these patients. We report the case of an ankylosing spondylitis patient with fixed neck deformity for laparoscopic bilateral inguinal hernia repair surgery managed with an Ambu® AuraGain™ laryngeal mask (LM) insertion and followed by a fibreoptic bronchoscopic-aided endotracheal tube insertion for definitive airway through the LM airway according to the All India Difficult Airway Association guidelines.

Our Experiences and Comparison of Total Extraperitoneal (TEP) And Transabdominal Preperitoneal (TAPP) Techniques in Laparoscopic Inguinal Herni Repair

Aim: In this study, it was aimed to compare the results of Total Extraperitoneal (TEP) and Transabdominal Preperıtoneal (TAPP) surgical methods in laparoscopic inguinal hernia repair.
 Methods: The data of 317 patients who underwent laparoscopic inguinal hernia repair surgery with the diagnosis of inguinal hernia between October 2016 and January 2021 in the General Surgery Clinic of SBU Sultan 2. Abdulhamid Han Training and Research Hospital were evaluated retrospectively. The wound dehiscence, swelling in the incision or scrotum, recurrence, and the postoperative day of returning to work were questioned. The results of TAPP and TEP methods were compared statistically.
 Results: In our study, the mean age of 317 patients who underwent surgery with TEP and TAPP methods was 50.5, and 27 of them were female and 290 were male. Postoperative recurrence was observed in 21 (6.6%) patients, wound dehiscence in 11 (3.4%) patients, swelling at the incision in 44 (13%) patients, and scrotal swelling in 30 (9.4%) patients. It was determined that the patients who underwent the TEP procedure returned to work after an average of 5.09 (1-30) days, and the patients who underwent the TAPP procedure after an average of 4.04 (1-14) days. When the two groups were compared, there was no significant difference between the groups in terms of return to work day in the postoperative period (p= 0.707), recurrence in the postoperative period (p=0.493), swelling at the incision (p=0.479), scrotal swelling (p=0.356), and wound dehiscence (p=0.245).
 Conclusions: There are two methods commonly used today in the repair of inguinal hernia by laparoscopic method. TEP method is performed in the preperitoneal area and TAPP method is performed in the intraperitoneal area. In this study, the results of TEP and TAPP methods were compared and it was found that there was no statistically significant difference between the two procedures in terms of postoperative recurrence, time to return to work and postoperative complications.

Effects of ultrasound guided caudal epidural and transversus abdominis plane block on postoperative analgesia in pediatric inguinal hernia repair surgeries

Ultrasound guided caudal epidural block (CEB) and transversus abdominis plane block (TAPB) are two techniques which are used for pain management after inguinal hernia surgeries (IHR). CEB is accepted as gold standard for lower abdominal surgeries while TAPB is more popular. It is aimed to compare ultrasound guided CEB and TAPB for postoperative pain scores, additional analgesic requirement and chronic pain development in pediatric bilateral open IHR. Seventy patients aged 1-7 years undergoing bilateral open IHR were included in this prospective, randomized, double-blinded study. Patients were randomized into group T (Bilateral TAPB) and group C (CEB). Postoperative FLACC (Face, Legs, Activity, Cry, Consolability) scores were evaluated for pain density. Additional analgesic requirement, length of hospital stay was also recorded. Chronic pain is evaluated within a subgroup by using "revised Bieri faces pain scale" in the postoperative second month. Postoperative 15th, 30th, 45th min, first, second hour FLACC scores were similar in both groups (P>0.05). In group C, FLACC scores at postoperative sixth and 24th were significantly higher than group T (1 (0-5) vs 0 (0-2); 1 (0-3) vs 0 (0-2), respectively; P<0.001). Additional analgesic requirement in the postoperative 24h was found to be statistically higher in Group C (56.7%) than in Group T (20%) (P<0.01). Chronic pain development did not differ between the groups (P>0.05). Length of hospital stay was found to be shorter in patients in Group T compared to patients in Group C [10 (5-14) vs 16 (5-18) hours, respectively; P<0.01)]. Our results exhibited that TAPB and CEB for bilateral IHR have similar early analgesic efficacy in children. However; CEB patients experienced higher FLACC scores at the postoperative sixth and 24th hours, and the need for additional analgesics was higher and the length of hospital stay was longer comparing to TAPB. Of note, chronic pain was not observed in any of our subgroup patients (n=21) who are older than four years. For bilateral IHR, US-guided CEB and TAPB have similar analgesic efficacy in the first six hours, postoperatively, However, TAPB appears to be slightly superior than CEB in terms of subacute pain and length of stay which is still not clinically distinctive.

Outpatient inguinal hernia repair in Spain: a population-based study of 1,163,039 patients—clinical and socioeconomic factors associated with the choice of day surgery

Reducing inpatient admissions and health care costs is a central aspiration of worldwide health systems. This study aimed to evaluate trends in outpatient surgery in inguinal hernia repair (IHR) and factors related to the outpatient setting in Spain. A retrospective cohort study (Record-Strobe compliant) of 1,163,039 patients who underwent IHR from January 2004 to December 2019 was conducted. Data were extracted from the public clinical administrative database CMBD (“Conjunto Mínimo Básico de Datos”). The primary outcome was the outpatient surgery rate. Univariate and multivariable analyses were performed to identify clinical and socioeconomic factors related to the outpatient setting. The overall proportion of outpatient repairs was 30.7% in 2004 and 54.2% in 2019 (p < 0.001). Treatment in a public hospital was the most remarkable factor associated with the likelihood of receiving an outpatient procedure (OR 3.408; p < 0.001). There were also significant differences favouring outpatient procedures for patients with public insurance (OR 2.351; p < 0.001), unilateral hernia (OR 2.903; p < 0.001), primary hernia (OR 1.937; p < 0.0005), age < 65 years (OR 1.747; p < 0.001) and open surgery (OR 1.610; p < 0.001). Only 9% of patients who pay for their intervention privately or 15% of those covered by private insurance were treated as outpatients. Spain has significantly increased the rate of outpatient IHR over the last 16 years. However, the figures obtained still leave a significant margin for improvement. Important questions about the acceptance of outpatient settings remain to be answered.Graphical Outpatient inguinal hernia repair in Spain. A population-based study of 1,163,039 patients: clinical and socioeconomic factors associated with the choice of day surgery.

P-067 FORMATION IN MINIMAL INVASIVE SURGERY IN INGUINAL HERNIA REPAIR IN GENERAL SURGERY RESIDENCY TRAINING: RESULTS OF A NATIONAL SURVEY

Abstract Aim To describe and assess how minimal invasive surgery in inguinal hernia repair is in spanish general surgery residency. Material &amp; Methonds An anonymus survey with 26 questions was sent to all Surgery Residents in Spain by email by Spanish Surgeons Association. Responses were analysed using both qualitative and quantitative methods. Results 161 answers were recieved. Residents of each year and each hospital answered that survey. 83.2% performed minimal invasive abdominal wall surgery. But in 78.2% of hospital this surgery was conducted by 1 or 2 senior surgeon. 55.1% performed less than 30 surgeries per year. TEP was preferred than TAPP in most cases. 51.2% of residents did not rotate in an abdominal wall surgery unit. At least 48% of residents did not performed any minimal invasive surgery during their residency training, but 71.4% performed their first open inguinal hernia repair at their first year of residency. Those who performed minimal invasive surgery, just 6% performed more than 20 surgeries. 91.9% of residents percieved gaps in their minimal invasive inguinal hernia repair surgery training. Conclusion Abdominal wall surgery is infraestimated. This survey findings highlighted the gaps and the callenges encouterd by Spanish General Surgery residents in acquiring satisfactory minimal invasive inguinal hernia surgery skills during their residency. An improvement in our formation is needed.

“Comparative Study to Evaluate Post Operative Pain in Management of Open Inguinal Hernia Repair With and Without Inguinal Nerve Block”

Background: Inguinal hernia repair is most frequently preformed surgeries by most of the general surgeons worldwide. Pain is the most common symptom post operative in both immediate and chronic phase. Pain management in these patients, especially in the immediate post operative time, is major concern for both patients and the medical fraternity.Material &amp; Methods: A comparative study to evaluate the post operative pain in management of open inguinal hernia repair with and without inguinal nerve block was conducted at Dept. of General Surgery in Santosh Medical College and Hospital, Ghaziabad on patients admitted in Dept of General Surgery from September 2020 to August 2021. All patients underwent Lichtenstein tension free mesh repair for inguinal hernia. Half the patients randomly selected were given inguinal nerve block using 0.25% levobupivicaine.Results: Nerve blocks have been used for chronic pain managements in past in post op inguinal hernia repair surgeries. Present study deals with pain management in immediate post- operative pain management. It shows significant difference is noted in patients receiving the nerve block not only in pain but also comfort levels, post operative mobility, day of discharge and retention of urine.Conclusion: Use of nerve blocks in patients undergoing open inguinal hernia repair is beneficial for the patient with improved outcome.

Prophylactic administration of alpha-blockers for the prevention of post-operative urinary retention following inguinal hernia repair: A meta-analysis of randomized control trials

BackgroundInguinal hernia repair is a commonly performed surgical procedure performed in adult males. Urinary retention following surgery is a known complication likely due to the adrenergic over-stimulation of smooth muscles in the bladder neck and prostate. This effect could potentially be mitigated by the use of alpha-blocker medications. A meta-analysis of randomized control trials (RCTs) was performed to analyse the evidence behind the use of alpha-blockers in the prevention of post-operative urinary retention (POUR). MethodsA comprehensive search of PubMed, Embase, MedLine and Scopus was undertaken adhering to PRISMA guidelines. RCTs using alpha-blockers as a single point intervention were included. Data were analysed using a random-effects model. Risk of Bias (ROB) was assessed according to Cochrane guidelines. ResultsSeven RCTs including 680 patients were included. The use of alpha-blockade reduced the incidence of urinary retention requiring catheterization (OR:0.23, 95% CI:0.07–0.70, p:0.009). No serious side-effects of alpha-blockers were reported. ConclusionAlpha-blockers are a safe and effective intervention to reduce the incidence of urinary retention following inguinal hernia repair surgery.

The transition from open to laparoscopic surgery for bilateral inguinal hernia repair: how we did it

PurposeTo describe the transition process from open repair (OR) to laparoscopic repair (LR) of bilateral inguinal hernia in a small basic general hospitalMethodsWe describe the technical details and training strategy used to facilitate the transition to systematic LR of bilateral inguinal hernia. We conducted a retrospective analysis of prospectively collected data from all patients undergoing bilateral inguinal hernia repair between January 2017 and December 2020. We analysed the evolution of LR and compared the surgical outcomes: complications, acute pain (24 h), chronic pain (> 3 months), and recurrence (1 year) of the patients operated on by OR and LR.ResultsWe performed 132 bilateral inguinal hernia repairs, 55 (41.7%) ORs, and 77 (58.3%) LRs. A significant difference was observed in the choice of LR over time (2017: 9%, 2018: 32%, 2019: 75%, 2020: 91%, p < 0.001). The mean operative time was shorter in the OR group than in the LR group (56 min vs. 108 min, p < 0.001). However, the operative time of the LR decreased over the years. No significant differences were observed in complications or recurrence. LR was associated with lower acute postoperative pain at 24 h (2.2 vs. 3.1 points, p = 0.021) and lower chronic groin pain than OR (1.3% vs. 12.7%, p = 0.009).ConclusionA structured and systematized training process made the transition from OR to LR of bilateral inguinal hernias feasible and safe in a small basic general hospital. This transition did not increase complications or recurrence. Additionally, LR was associated with a decrease in postoperative pain and chronic groin pain.

EP-503 An Audit of Day case surgery for Inguinal Hernia Repair

Abstract Aims To compare the trust-wide performance with the standard by the British Association of Day Surgery in the management of inguinal hernias. Methods Electronic data of patients who underwent Inguinal Hernia Repairs in the trust from September 2019 to December 2019 was analyzed. Results A total of 122 male and 11 female patients had hernias repaired in this time period.18 were emergency while the rest of the cases were elective. The ages ranged from 19–91 with a mean age of 62. Of the 115 electives, 60% were performed as day-case. The mean length of stay was 1.7days (R 0–12).34 out of 46 (74%) patients who stayed inpatient were actually booked as day-case. 73% had no documented reason for their admission.4 patients were admitted for medical reasons 2 for post-operative surgical complications. Of patients pre-booked as inpatients,10 were quoted to have serious medical issues while 5 had no clear reason. The vast majority had open repairs while 26% of the 115 patients had laparoscopic repairs. Conclusion Our Performance was noted to be 30% lower than the BADS standard. There is a need of: Development of inpatient surgery booking criteria and adherence. Discussion with anesthetic colleagues to assist drive towards day-case surgery. Clear documentation in the clinical letters to explain the reason for inpatient management and booking. Perioperative notes need improvement.

POST OPERATIVE ANALGESIA AFTER SPINAL ANAESTHESIA WITH MORPHINE AND BUPIVACAINE VERSUS FENTANYL AND BUPIVACAINE FOR UNILATERAL INGUINAL HERNIA REPAIR IN ADULT MALE : A COMPARATIVE STUDY

Background: The study is aimed to compare the effects of intrathecal fentanyl and intrathecal morphine combined with 0.5% hyperbaric bupivacaine on the quality of postoperative pain control for unilateral inguinal hernia repair in adult male population. Fifty –ve patients aged 18-60 years with American Society of Anesthesiologists physical status I-IIMaterials and Methods: scheduled for elective inguinal hernia repair surgery were enrolled in this prospective randomized double blinded study. Patients received spinal anesthesia with either 25 mcg fentanyl plus 15 mg heavy bupivacaine intrathecally (group F, n=55) or 0.2 mg morphine plus 15 mg heavy bupivacaine intrathecally (group M, n=55).Hemodynamic parameters, time to rst analgesic requirement, postoperative pain scores, the number of analgesic requirements and side effects over postoperative 24 h were recorded Pain scores were signicantly lower in group MResults: compared with group F in the postoperative 24 h. The time to rst analgesic requirement was higher in group M than group F. Analgesic requirement was higher in group F than group M for the rst 24 hours, postoperative We concluded that the addition of 0.2 mgConclusion: morphine intrathecally to 15 mg heavy bupivacaine provides improved postoperative analgesia than 25 mcg fentanyl for inguinal hernia repair under spinal anesthesia.

Comparison between Caudal and TAP Blocks Post-Inguinal Surgery Analgesia in Children

Background: The optimal and lonely method to achieve typical analgesia post-inguinal surgeries in children is still not determined. This study compared the analgesic efficacy and adverse effects between caudal analgesia and TAP (Transversus Abdominis Plane) block. Methods: 40 children (male) between 3-9 years old, with parental consent and institutional board approval, undergoing elective inguinal hernia repair surgery, randomly divided in two groups were enrolled in this study. Both groups received induction on Sevoflurane, Fentanyl, Propofol and Atracurium (dose dependent), with laryngeal mask airway and mechanical ventilated, maintenance on Sevoflurane and smoothly recovered. The first group (C) received caudal analgesia of Bupivacaine 0.25% (1ml/kg). The second group (T) received TAP block of Bupivacaine 0.25% (0.5 ml/kg). Pain was assessed by CHEOPS (Children's Hospital of Eastern Ontario Pain Scale). Parents also assessed pain (after explain and orient them) with Wong-Baker scale 0 (no pain) and 10 (worst pain imaginable). Results: The first group (C) of patients had about 240 ± 30 minutes, while the second group (T) had about 360 ± 60 minutes, early ambulation and feeding and finally, most of them missed the pain till they were home discharged. Conclusion: TAP block enhances comfortable long-time post-op state for the patients, especially the young age group as they are hardly pain dealt off. Also TAP block has an easily performed procedure with less dose and complications compared to the caudal ones.

An estrogen-sensitive fibroblast population drives abdominal muscle fibrosis in an inguinal hernia mouse model.

Greater than 25% of all men develop an inguinal hernia in their lifetime, and more than 20 million inguinal hernia repair surgeries are performed worldwide each year. The mechanisms causing abdominal muscle weakness, the formation of inguinal hernias, or their recurrence are largely unknown. We previously reported that excessively produced estrogen in the lower abdominal muscles (LAMs) triggers extensive LAM fibrosis, leading to hernia formation in a transgenic male mouse model expressing the human aromatase gene (Aromhum). To understand the cellular basis of estrogen-driven muscle fibrosis, we performed single-cell RNA sequencing on LAM tissue from Aromhum and wild-type littermates. We found a fibroblast-like cell group composed of 6 clusters, 2 of which were validated for their enrichment in Aromhum LAM tissue. One of the potentially novel hernia-associated fibroblast clusters in Aromhum was enriched for the estrogen receptor-α gene (Esr1hi). Esr1hi fibroblasts maximally expressed estrogen target genes and seemed to serve as the progenitors of another cluster expressing ECM-altering enzymes (Mmp3hi) and to upregulate expression of proinflammatory, profibrotic genes. The discovery of these 2 potentially novel and unique hernia-associated fibroblasts may lead to the development of novel treatments that can nonsurgically prevent or reverse inguinal hernias.

A comparative study between ultrasound-guided ilioingunial/iliohypogastric nerve block versus transverse abdominis plane block in patients undergoing oblique inguinal hernia repair

BackgroundCombined ilioinguinal-iliohypogastric (IIN/IHN) block and transverse abdominis plane (TAP) block are used under ultrasound (USG) visualization for postoperative pain control in patients undergoing inguinal hernia repair surgery. This study compares USG-guided TAP versus IIN/IHN block for post-operative analgesia efficacy in adults undergoing inguinal hernia surgery, among 100 patients randomized into group A received TAP block by using levobupivacaine 0.5% 25 ml and group B received IIN+IHN blocks by using levobupivacaine 0.5% 10 ml before induction of general anesthesia.ResultsThe mean duration (in minutes) to require rescue analgesia was found to be 1003.2 ± 99.6 (min) in group A and 1317 ± 69 (min) in group B. In a comparison of these two values the difference in the meantime to rescue analgesic requirement was statistically significant (p < 0.001).ConclusionsUSG-guided IIN/IHN block delays the need for rescue analgesia and reduces the postoperative analgesic requirement compared to USG-guided TAP block.

Multi-Slice Computed Tomography in Assessing Mesh Titanium Implant Shrinkage After Prosthetic Inguinal Hernioplasty

Objective: to assess the percentage of mesh “titanium silk” implant shrinkage after inguinal hernia repair surgery in the late postoperative period using multi-slice computed tomography (MSCT). Material and methods. The comparative assessment of the long-term results of treatment in 90 patients with inguinal hernias was performed using MSCT. In 36 (40%) patients of Group 1 the titanium implant was used in Lichtenstein hernia repair surgery. In Group 2, 54 (60%) patients were operated by laparoscopic hernia repair surgery. On day 3 and 3 months after surgery every patient underwent MSCT with subsequent determination of the implant square. Results. The percent of mesh “titanium silk” implant shrinkage 3 months after surgery according to MSCT was 4.4% in Lichtenstein hernia repair group, and 8.3% in laparoscopic hernia repair group. According to Kruskal-Wallis test, there were no statistic differences of this indicator between two groups (p = 0,185). Conclusion. The analysis of long-term results of inguinal hernia repair surgery with titanium mesh implants using MSCT showed that implant square significantly decreases 3 months after surgery. There were no significant differences in implants shrinkage regarding the type of surgery. MSCT is an effective method for evaluating the size of mesh titanium implants after hernia repair surgery.

Comparison of complications of surgical repair in inguinal hernia with Bassini, Lichtenstein, and preperitoneal methods

Introduction: Complication after inguinal hernia repair is one of the challenging problems after inguinal hernia repair. This study aimed to compare the complications of three common surgical methods in inguinal hernia repair, Bassini, Lichtenstein, and Preperitoneal methods (with anterior approach). Methods: In this prospective study, patients who underwent inguinal hernia repair surgery in Baqiyatallah Hospital from June 2019 to May 2020 were included. Patients were allocated in three groups: Bassini, Lichtenstein, and Preperitoneal (with anterior approach), based on surgeons' opinions. Postoperative pain, hematoma and seroma, wound infection, recurrence, and also we assed postoperative satisfaction after surgery. Results: The mean age of patients was 49.90 ± 16.44 years, and 92.5% of patients were male. Of the total patients, 6.8% had an infection and there was no significant difference in the distribution of infection in the groups (P=0.230). The mean of pain in all patients was 2.37 ± 1.10. There was no significant difference between the three groups in the mean of pain (P = 0.253). There was no significant difference in the distribution of recurrence in the groups (P=0.356). There was no significant difference in the distribution of testicular swelling in the groups (P=0.421). No postoperative hematoma and seroma were reported in the groups. The mean of satisfaction in all patients was 93.61±19.63. There was no significant difference between the three groups in the mean of satisfaction (P = 0.156). Conclusion: The results showed that infection, pain, and recurrence rate in the Preperitoneal group were lower than the other groups, although this difference was not significant. Also, testicular swelling, hematoma, and seroma as well as patients’ satisfaction were similar between groups.

Evaluation and Comparison on the Results of Totally Extraperitoneal Laparoscopic Surgery under General and Spinal Anesthesia for Inguinal Hernia.

Totally extraperitoneal (TEP) hernia repair surgery is one of the recently considered hernioplasty methods. Here, in the current study, we aimed to compare the results of TEP hernia repair surgery in the two groups of general anesthesia and spinal anesthesia. This is a randomized clinical trial that was performed in 2018-2019 in Isfahan on 106 patients undergoing TEP inguinal hernia repair. Patients were randomly divided into two groups. The first group underwent TEP inguinal hernia repair surgery under general anesthesia and the second group of patients underwent TEP inguinal hernia repair surgery under spinal anesthesia. Data regarding surgery duration, intensive care unit admission, pain of patients, mean of analgesic injections after the surgery, and complications such as urine retention, seroma, and hematoma, and wound infection were collected. Data were compared between two groups. We found significantly higher duration of surgery in the spinal anesthesia group (P = 0.02). Patients in the spinal anesthesia group had shorter duration of nutrition regime beginning (P = 0.002) and lower frequencies of urine retention (P = 0.001). Further analysis showed that the mean pain severity was significantly lower in spinal anesthesia group compared to general anesthesia during postoperation measurements (P = 0.001) and patients in spinal anesthesia group received less postoperation analgesics compared to the other group (P = 0.001). TEP surgery under spinal anesthesia was associated with better clinical results such as lower postoperative pain and analgesics injections compared to general anesthesia.

How to Establish the Bipolar Forceps Dissection Method in Robotic Inguinal Hernia Repair.

The number of robotic inguinal hernia repair (RIHR) surgeries performed by younger surgeons and surgical residents has been growing worldwide. As a result, there has been growing interest in the pace at which surgeons develop their competencies. In Japan, the number of robotic surgeries with the double bipolar technique for gastric cancer is increasing. We devised an RIHR technique for a right‐hand‐dominant surgeon. This article describes the procedure and step‐by‐step instructions for this technique. We also assessed the learning curve of a surgeon experienced in the laparoscopic transabdominal preperitoneal (TAPP) approach and robotic gastrectomy. This was a retrospective review of 31 inguinal hernia patients (40 lesions) between December 2018 and April 2021 operated by a single surgeon. The cumulative summation technique (CUSUM) was used to construct a learning curve for robotic proficiency by analyzing the times for peritoneal flap creation, mesh placement, and peritoneal closure. The postoperative course, namely, the length of hospital stay, 30‐d complications, and 30‐d readmission rates, was evaluated. The CUSUM graph for the total time for each phase indicated an initial decrease at lesion 12 and another decrease at lesion 36, generating three distinct performance phases: learning (n = 12 procedures), competence (n = 24), and mastery (n = 4). Between the early and late periods, no significant differences in patient characteristics or surgical outcomes were found. The learning curve for this technique was divided into three performance phases, and the technique was safely achievable in 36 procedures by a surgeon with previous experience in laparoscopic TAPP.

Autonomous Hierarchical Surgical State Estimation During Robot-Assisted Surgery Through Deep Neural Networks

Many operations in robot-assisted surgery (RAS) can be viewed in a hierarchical manner. Each surgical task is represented by a superstate, which can be decomposed into finer-grained states. The estimation of these discrete states at different levels of temporal granularity provides a temporal perception of the current surgical scene during RAS, which is a crucial step towards many automated surgeon-assisting functionalities. We propose Hierarchical Estimation of Surgical States through Deep Neural Networks (HESS-DNN), a deep learning-based system that concurrently estimates the current super- and fine-grained states. HESS-DNN incorporates endoscopic vision, robot kinematics, and system events data from the da Vinci Xi surgical system. HESS-DNN is evaluated on a real-world robotic inguinal hernia repair surgery dataset: HERNIA-20, and achieves accurate state estimates of both surgical superstate and the corresponding fine-grained surgical state. We show that HESS-DNN improves state-of-the-art fine-grained state estimation across the entire HERNIA-20 RAS procedure through its hierarchical design. We also analyze the relative contributions of each input data type and HESS-DNN's design to surgical (super)state estimation accuracy.