Laparoscopic Hernioplasty Research Articles

Use of Human Fibrin Glue (Tissucol) Versus Staples for Mesh Fixation in Laparoscopic Transabdominal Preperitoneal Hernioplasty

The aim of this study was to compare the morbidity of fixation of prosthetic meshes using Tissucol fibrin glue versus staples in laparoscopic transabdominal preperitoneal (TAPP) repair of inguinal and femoral hernias. In patients undergoing laparoscopic hernia repair, fixation of mesh prostheses with staples may affect inguinocrural nerves causing early postoperative neuralgia and chronic neuralgia. Between June 2003 and February 2005, 197 patients with inguinal or femoral hernia were enrolled in this prospective, randomized study, to assess morbidity following hernia repair with staples (n = 98) or Tissucol (n = 99). The primary outcomes were early postoperative and late neuralgia recorded using a visual analog scale (VAS). The effects of neuralgia on functional status were evaluated using the modified SF-36 questionnaire. Secondary outcomes included complications such as nonspecific pain and recurrence. Assessments took place at 1, 3, 6, and 12 months, with all patients completing each follow-up visit. Mean VAS scores were significantly lower in the Tissucol group versus the staples group (MANOVA, P < 0.05). Higher scores for the modified SF-36 questionnaire at 1 month were demonstrated in the Tissucol group compared with the staples group (23.2 and 22.6, respectively; P < 0.05). The mean recovery time for normal physical activity was significantly shorter in the Tissucol group compared with the staples group (7.9 vs. 9.1 day, respectively; P < 0.001). One recurrence was seen in the fibrin glue group, which was attributable to a technical error in fixation of the mesh. The use of Tissucol provides distinct advantages in laparoscopic treatment of inguinal/femoral hernias compared with conventional TAPP, including a lower incidence of postoperative neuralgia and an earlier resumption of physical and social activities.

Laparoscopic Repair of Incarcerated Low Spigelian Hernia With Transperitoneal PTFE DualMesh

There are different types of hernias that can develop at certain sites in the abdominal wall. Spigelian hernia (SH) is a protrusion of abdominal contents through a defect in the spigelian aponeurosis, in proximity to the external margin of the rectus muscle. Usually, abdominal wall hernia sac contains the omentum but may also contain small intestine that might become trapped in the hernia. When ischemia of herniated contents is suspected, urgent surgical treatment is advocated. Elective laparoscopic repair of SH is still under discussion. However, a recent randomized study comparing open and laparoscopic repair as elective treatment suggested that extraperitoneal laparoscopic repair is the technique that offers best results for the patients. Recent development of new biologic materials and technologies in laparoscopy has led to improved results. We report the successful repair of incarcerated low SH that was successfully managed by urgent laparoscopic intraperitoneal onlay polytetrafluoroethylene mesh hernioplasty.

Incidence of occult inguinal and spigelian hernias during laparoscopy of other reasons

A true incidence of occult inguinal and Spigelian hernias in adult population is unknown. The frequency of incipient hernias was studied during laparoscopy of other abdominal diseases. The 201 laparoscopic procedures included 104 cholecystectomies, 55 fundoplications, 36 diagnostic, and 6 miscellaneous operations. There were 133 females and 68 males with a mean age of 53 +/- 14 years. The orifices of all inguinal and Spigelian hernias were carefully recorded at the beginning of laparoscopy by using 30 degrees optic. The overall frequency of unexpected hernias was 43 of 201 (21%) including 36 (18%) inguinal hernias, 5 (2%) Spigelian hernias and 2 (1%) ventral hernias. The number of hernias was higher in males than in females (P = .003). The most common finding was indirect inguinal hernia in 27 (13%) subjects. Usually hernia orifices were insignificant and only 5 of 201 laparoscopic hernioplasties were undertaken without any complications. Occult hernia orifices are commonly found in laparoscopic operation. Usually the defects are asymptomatic and hernioplasty is not needed. Herniation of Spigelian fascia is rare (<2%) in adults during laparoscopy.

Hernioplastie inguinale sous-péritonéale par voie antérieure, à l'aide d'une prothèse à mémoire de forme. Résultats préliminaires

Objective Incidence of chronic pain is lower following laparoscopic hernioplasty than open surgery, probably due to the location of the patch in the preperitoneal space. But since laparoscopy is more demanding, the rates of complications and recurrences are higher. The aim of this study was to evaluate the results of a procedure consisting of placement of a patch, endowed with some memory of shape, provided by a thin peripheral memory ring, in the preperitoneal space, by inguinal incision, through the hernia orifice, under spinal or local anesthesia. Methods The study was carried out in two stages. The first study consisted of evaluating the results of a prosthesis made of a polypropylene mesh endowed with a memory-ring made of a PDS cord (Ethicon SAS, 92787 Issy-les-Moulineaux). The second study evaluated the results of the Polysoft ® patch manufactured by Bard C° (Bard France, 78960 Voisins-le-Bretonneux), according to this concept. Results The first study involved 129 hernias operated on 126 patients of mean age 60 years (27–84). There were 3 (2.3%) benign complications. With a median follow-up of 24.5 months (12–42), 124 hernias (96%) were evaluated. There were 2 recurrences (1.6%) and 7 cases (5.6%) of chronic pain. The second series involved 150 hernias operated on 139 patients of mean age 60 years (21–94). Four (2.7%) benign complications occurred. The median length of surgery was 36 min (20–60), the median postoperative hospital stay was 1 day (0–5), the median time to return to normal activity was 3 days (0–8) and the median time off work was 18 days (1(30). The patients took paracetamol for 3 days (0–10) and the total units number was 8 (0–28). Conclusion These results suggest that the method, easily reproducible, provides a low rate of complications and recurrences, as well as a low level of postoperative and chronic pain. They are worth being confirmed by a randomised comparison to the laparoscopic and Lichtenstein techniques.

TAPP - Stuttgart technique and result of a large single center series

Laparoscopic hernioplasty is assessed as a difficult operation. Operative technique determines the frequency of complications, the time of recovery and the rate of recurrences. A proper technique is absolutely necessary to achieve results that are superior to open hernia surgery. The key points in our technique are 1) use of nondisposable instruments; 2) use of blunt trocars, consisting of expanding and non-incisive cone-shaped tips; 3) spacious and curved opening to the peritoneum, high above all possible hernia openings; 4) meticulous dissection of the entire pelvic floor; 5) complete reduction of the hernial sac; 6) wide parietalization of the peritoneal sac, at least down to the mid of psoas muscle; 7) implantation of a large mesh, at least 10 cm × 15 cm; 8) fixation of the mesh by clip to Cooper's ligament, to the rectus muscle and lateral to the epigastric vessels, high above the ileopubic tract; 9) the use of glue allows fixation also to the latero-caudial region; and 10) closure of the peritoneum by running suture. With this technique in 12,678 hernia repairs, the following results could be achieved: operating time - 40 min; morbidity - 2.9%; recurrence rate - 0.7%; disability of work - 14 days. In all types of hernias (recurrence after previous open surgery, recurrence after previous preperitoneal operation, scrotal hernia, hernia in patients after transabdominal prostate resection), similar results could be achieved. Laparoscopic hernia repair can be performed successfully in clinical practice even by surgeons in training. Precondition for the success is a strictly standardized operative technique and a well-structured educational program.

Unusual complications of laparoscopic totally extraperitoneal inguinal hernia repair

Although complications of laparoscopic totally extraperitoneal inguinal hernia repairs are well documented, the development of pneumothorax, pneumomediastinum and subcutaneous emphysema is rarely reported. The authors' experience with a 23-year-old man who developed intraoperative bilateral pneumothoraces and cervical subcutaneous emphysema during a laparoscopic totally extraperitoneal inguinal hernia repair prompted a MEDLINE literature review. Seven similar cases were found in which the patients developed pneumothorax, pneumomediastinum and/or subcutaneous emphysema following laparoscopic hernioplasty. An intercostal catheter was inserted in two out of the seven patients only. Numerous hypotheses were proposed for the development of these complications. Several authors felt that the duration of the procedure and preperitoneal insufflation pressures are related to the development of these complications. These potentially lethal complications must be diagnosed and managed promptly.

General Anesthesia for Surgery Influences Melatonin and Cortisol Levels

The purpose of this study was to investigate the effect of general anesthesia and surgery on melatonin production, and to assess the relationship between melatonin secretion and cortisol levels. Twenty (9 males and 11 females) consecutive otherwise healthy patients aged 27 to 52 years were included in this study. The patients underwent laparoscopic cholecystectomy or laparoscopic hernioplasty. All patients had general anesthesia with the same anesthetic drugs. Serum cortisol levels were measured at several time periods. Urine collections for melatonin were performed from 18:00 to 7:00 the day prior to surgery, on the operation day, and on the first postoperative day. Baseline melatonin metabolites were measured the night prior to surgery, and the level was found to be 1979 +/- 1.76 ng. The value decreased to 1802 +/- 1.82 ng (NS) on the night of surgery, and it became a significantly higher, reaching 2981 +/- 1.55 ng the night after surgery (p = .003). The baseline daytime cortisol level was significantly lower than the baseline night cortisol level (6.87 +/- 1.51 microg/dl, 14.89 +/- 1.66 micrograms/dl, respectively, p < 0.0001). Surgery induced a significant increase in both day and night cortisol levels. Daytime cortisol levels increased from 6.89 +/- 1.51 microg/dl to 16.90 +/- 1.27microg/dl (p < 0.0001), whereas right levels increased from 14.89 +/- 1.66 microg/dl to 29.20 +/- 1.24 microg/ dl (p <0.0001). The morning after surgery, cortisol levels decreased to 10.16 +/- 1.40 microg/dl, lower than the value obtained on the day of surgery (p < 0.0001). As was true of melatonin, cortisol levels did not reach the pre operative level (p < 0.005). The finding of the current study is that melatonin and cortisol levels show an inverse correlation after surgery.

Prosthetic mesh hernioplasty during laparoscopic radical prostatectomy

Objectives To evaluate the role of simultaneous laparoscopic mesh prosthetic hernioplasty during laparoscopic radical prostatectomy (LRP), because 5% to 10% of candidates for radical prostatectomy present with a detectable inguinal hernia at their preoperative physical examination. Moreover, data have suggested a greater incidence of inguinal hernia after open radical prostatectomy. Methods During 1035 LRP procedures, 50 laparoscopic mesh prosthetic hernioplasty procedures were performed in 37 patients (3.6%) for 13 bilateral and 24 unilateral inguinal hernias. We compared the outcome of LRP with simultaneous laparoscopic inguinal hernioplasty (group 1) with that of 37 match-paired patients treated by LRP alone (group 2). Both groups were matched according to age, prostate-specific antigen level, prostate volume, pathologic stage, and Gleason score. Perioperative parameters (ie, operative time, analgesic requirements) and postoperative results were analyzed. Results The patient age was 64.1 ± 6.4 years versus 62.8 ± 4.9 years old and had a body mass of 26.5 ± 3.0 versus 27.4 ± 3.2 kg/m 2 in groups 1 and 2 (with and without laparoscopic hernioplasty), respectively. The mean operating time (221.9 versus 191.2 minutes, P = 0.011) and the total amount of narcotic analgesic requirements (26.8 mg versus 17.5 mg, P = 0.026) was significantly increased in the patients who underwent simultaneous laparoscopic inguinal hernia mesh repair. No statistically significant difference was found in the complication rate (4% versus 2%), median catheter time (7 days), and positive surgical margins (21.8%). Conclusions Simultaneous repair of inguinal hernia during LRP using prosthetic mesh is feasible without adverse effects on surgical and functional parameters. Neither the transperitoneal nor extraperitoneal approach is associated with an increase in complications or morbidity. However, an extraperitoneal access allows an easier repair without the refixation of the peritoneum.

Laparoscopic totally extraperitoneal inguinal hernioplasty: The use of a contoured three‐dimensional mesh

Recent literature on laparoscopic inguinal hernia repair (LIHR) has shown that laparoscopic hernioplasty is associated with reduced postoperative pain and wound infection, and an earlier return to normal daily activities. The technique of LIHR is still evolving. We descibe our technique and experience in performing laparoscopic hernioplasty using a contoured three‐dimensional mesh without the application of endoscopic staples.

A Laparoscopic Approach for Incarcerated Spigelian Hernia

Incarcerated Spigelian hernia (SH) is an uncommon surgical emergency that demands immediate operative treatment. In the era of minimal access surgery, elective laparoscopic repair of uncomplicated SH is safe and feasible. Herein, we report a case of incarcerated Spigelian hernia that was successfully managed by laparoscopic hernioplasty on an emergent basis.

Inguinal hernia repair in Hospital Authority hospitals: The role of laparoscopic hernioplasty

Objective: Two major changes have occurred in inguinal hernia repair during the last two decades: (i) the use of tension‐free mesh repair; and (ii) the application of laparoscopic technique for repair. The aims of the present study were to study: (i) how inguinal hernia repair was carried out; and (ii) the outcome of inguinal hernia repair in Hospital Authority (HA) hospitals.Methodology: This was a retrospective analysis on 8311 elective inguinal hernia repairs performed in 16 HA hospitals from January 2001 to December 2003. The mean age was 63.9 ± 14.2 years, and the male to female ratio was 22.0 : 1.0. Among these, 869 (10.5%) repairs were performed with the laparoscopic approach and 7442 (89.5%) repairs with the open approach. The proportion of laparoscopic hernia repair increased from 8.7% to 12.6%.Results: For open repair, 39% of cases were carried out with regional anaesthesia, 32% with general anaesthesia and 29% with local anaesthesia (LA). Furthermore, mesh repair was used in 88% of the patients. For laparosocpic repair, 98.4% of cases were carried out under general anaesthesia, and all patients had mesh repair using the totally extraperitoneal approach. A significantly higher proportion of bilateral repair and recurrent hernia repair was performed with the laparoscopic approach (P = 0.000). For primary unilateral repair, there was no significant difference in the postoperative length of stay (LOS) and the total LOS between the laparoscopic and the open surgery groups. No difference in LOS was found in recurrent hernia repair between the two groups. With respect to bilateral repair, both the preoperative LOS (P = 0.036) and total LOS (P = 0.039) were shorter in the laparoscopic group. Furthermore, a significantly higher proportion of day‐surgery patients was observed in the laparoscopic group than the open surgery group (21.3%vs 16.9%, P = 0.001). Nevertheless, when only the results of 2003 were analyzed, the postoperative LOS (P = 0.000) and total LOS (P = 0.000) were significantly shorter in the laparoscopic group than the open surgery group. The LOS parameters were significantly shorter in the open surgery LA subgroup compared with the non‐LA subgroup (P = 0.000), and they were not different from those in the laparoscopic group.Conclusions: The open mesh repair is the predominant approach for inguinal hernia repair in HA hospitals. The originally described local anaesthetic approach was under utilized, although it resulted in good outcome. The use of laparoscopic hernia repair is increasing and a learning curve was recently observed with improved outcome.

Intestinal obstruction after inguinal and femoral hernia repair: a study of 33,275 operations during 1992–2000 in Sweden

The risk of intra-abdominal intestinal obstruction after open or laparoscopic hernioplasty is, to our knowledge, not known. The transabdominal laparoscopic (TAPP) route brings a potential risk of abdominal adhesions, which may increase the risk of postoperative intestinal obstruction. The pre-peritoneal route laparoscopically, totally extraperitoneal laparoscopic hernioplasty (TEP), should not increase this risk since the abdominal cavity is not entered. The Swedish Hernia Register, with 33,275 patients operated on for single primary unilateral groin hernia during the period 1992-2000, was linked to the Swedish Inpatient register and the Swedish Death register for the period 1987-2000. The risk of postoperative intestinal obstruction was low, 1.02 per 1,000 personyears. The highest adjusted relative risks (RR) were found in patients with previous admissions for abdominal inflammations or operations. The risk increased with the number of admissions. After an acute operation, and in patients older than 60 years, there was also a significantly increased risk. The RR was 2.79 (95% CI 1.01-7.42) after TAPP and 0.57 (95% CI 0.07-4.33) following TEP compared to patients operated on by the Lichtenstein method. None of the patients undergoing open hernia operations had a significantly increased risk. TAPP increased the risk of postoperative intestinal obstruction, but other risk factors, especially previous abdominal surgery or inflammation, have greater influence.

Umbilical hernia in adults

There is no consensus on the best technique for the repair of umbilical hernia in adults. The role of laparoscopic hernioplasty of umbilical hernia remains controversial. This study was undertaken to compare the outcomes of open and laparoscopic onlay patch repair of umbilical hernia in adults. From January 1996 to December 2002, 102 patients underwent elective repair of umbilical hernia. Operative techniques included Mayo repair ( n = 43), laparoscopic onlay Gore-Tex patch hernioplasty ( n = 26), suture herniorrhaphy ( n = 24), and mesh hernioplasty ( n = 9). Demographic features and risk factors were similar among the four groups. The operative time of laparoscopic hernioplasty (median, 66 min) was significantly longer than those for patients who underwent Mayo repair (60 min) or sutured herniorrhaphy (50 min) ( p < 0.05). None of the patients who underwent laparoscopic patch repairs required conversion to open repair. The median pain score at rest on postoperative day 1 was significantly lower in patients who underwent laparoscopic repair compared to those who had Mayo repair. A significantly shorter hospital stay and a lower wound morbidity rate were also observed in patients who underwent laparoscopic repair. With a mean follow-up of 2 years, suture herniorrhaphy had a relatively high recurrence rate (8.7%), whereas no recurrence was documented for the other techniques. Laparoscopic onlay patch hernioplasty is a safe and efficacious technique for the repair of umbilical hernia. Compared to Mayo repair, the laparoscopic approach confers the advantages of reduced postoperative pain, shorter hospital stay, and a diminished morbidity rate.

Hernia Operations Using Laparoscopic Hernioplasty on Military Personnel with a Short Hospitalization Time

Laparoscopic hernioplasty was performed by either transabdominal preperitoneal or totally extraperitoneal approaches, The purpose of this study was to demonstrate that laparoscopic hernioplasty is a way to treat military personnel in the army with less pain and for the patients to return to an active lifestyle in a short time. A total of 217 laparoscopic hernioplasty were performed in 192 patients. Eighty-eight hernias were operated by transabdominal preperitoneal and the 146 hernias were operated by totally extraperitoneal approach hernioplasty. The mean +/- SD operation times were 69.4 +/- 23.94 and 58.3 +/- 24.13 minutes for the transabdominal preperitoneal and the totally extraperitoneal approach, respectively (p = 0.42). Postoperative pain was monitored by the visual analog scale. Hospitalization time for patients without complications was significantly shorter (p = 0.02). Laparoscopic hernioplasty could be performed on military personnel who need to return to work quickly with a short hospitalization time, less pain, and lower recurrence rate.

Metaanálisis de los ensayos clínicos que comparan angioplastia primaria y tratamiento trombolítico en los pacientes con infarto de miocardio

The aim of this article is to explore the clinical effects between open extraperitoneal approaches and totally extraperitoneal laparoscopic hernioplasty (TEP) in the repair of inguinal hernias.The electronic databases Pubmed, Medline, Embase, Web of science and the Cochrane Library were used to search for articles from January 1992 to March 2013. The present meta-analysis pooled the effects of outcomes of a total of 1157 patients with 1377 hernias enrolled into 10 randomized controlled trials and 2 comparative studies. The data was analyzed using the statistic software Stata12.0 and IBM SPSS Statistics 19.Significant advantages of totally extraperitoneal laparoscopic hernioplasty (TEP) compared to the open extraperitoneal approach include a lower incidence of total postoperative complications (Odds Ratio, 0.544; 95% confidence interval, 0.369–0.803), a reduction in urinary problems (0.206[0.064,0.665]), an earlier return to normal activities or work (SMD = −1.798[−3.322,−0.275]), and a shorter length of hospital stay (−1.995 [−2.358,−1.632]). No difference was found in operative time, the incidence of hernia recurrence, chronic pain, intraoperative complications, seromas or hematomas, wound infection and testicular problems between the two techniques. One significant advantage for the open extraperitoneal inguinal hernia repair was a lower incidence of peritoneal tears (46.504 [15.399,140.437]).Totally extraperitoneal laparoscopic hernioplasty (TEP) and open extraperitoneal mesh repair are equivalent in most of the analyzed outcomes. TEP is associated with shorter hospital stay, quicker return to normal activities or work, lower incidence of total postoperative complications and urinary problems, while the open extraperitoneal method has less incidence of peritoneal tears.

Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia.

This study reviewed our experience with laparoscopic ventral postoperative (incisional) hernia repair. Clinical data from the first 100 cases were analyzed retrospectively. Between 1997 and 2000, 64 women and 36 men (mean age, 58.4 +/- 13.6 years; range, 27-87 years) underwent laparoscopic hernioplasty. Hernias (mean diameter, 6.2 +/- 3.7 cm) were in a midline (74%), subcostal (10%), or other incision location, and were recurrent in 25%, of the patients. The mean operative time was 119 +/- 77 min. Extensive adhesiolysis was necessary in 37 cases. There was no mortality. The recorded complications included inadvertent enterotomies (n = 6), seromas (n = 11), prolonged ileus (n = 4), and prolonged fever (n = 3). Seven cases were converted; to repair accidental enterotomies (n = 4) due to difficult adhesiolysis (n = 2), or to control bleeding (n = 1). Six patients underwent reoperation because of enetric leak (n = 3) or bowel obstruction (n = 3). There were two documented recurrences (2%). The mean follow-up period was 19 months (range, 12-54 months). Laparoscopic intraperitoneal approach to postoperative ventral (incisional) hernia repair may be associated with significant complications and morbidity, which can be prevented in part by meticulous technique and liberal conversions. The justification of this procedure is the low recurrence rate, according to preliminary results.

A unified approach to recurrent laparoscopic hernia repairs.

The problem of recurrence after laparoscopic hernia repair is relatively new, and the best way to handle it remains uncertain. The question of whether an open approach, a laparoscopic approach, or some combination of techniques should be preferred has not yet been resolved. The purpose of this study was to determine if the laparoscopic approach could deal with the problem safely and successfully. A retrospective review was done of the cases performed at the Center for Hernia Repair by one surgeon between July 1991 and September 1999. Laparoscopic hernioplasties for hernias that had previously been repaired laparoscopically were analyzed. All remedial repairs were begun using a transabdominal approach. Seventeen of 1960 hernias repaired were for failed laparoscopic repairs. Ten were repaired totally laparoscopically and two via an open approach with mesh, while five required a small anterior counterincision. There were no serious complications and one recurrence. The laparoscopic transabdominal approach to failed laparoscopic repairs is feasible, safe, and reliable when used in combination with a modified anterior approach when appropriate.

Is a dissection balloon beneficial in totally extraperitoneal endoscopic hernioplasty (TEP)?

Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to facilitate the creation of the initial working space in totally extraperitoneal endoscopic hernioplasty (TEP), but their use adds to the cost of the operation. A total of 322 men with unilateral, primary, or recurrent inguinal hernias were randomized to undergo TEP with or without a dissection balloon. In the group with the balloon, three of 161 patients (2.5%) required conversion to transabdominal preperitoneal hernioplasty (TAPP), or open herniorraphy, whereas 17 of 161 patients (10.6%) were converted to TAPP or open herniorraphy in the group without the balloon (p = 0.002). The mean operation time was 55 min in the group with the balloon and 63 min in the group without the balloon (p = 0.004). There was no difference between them in postoperative morbidity, and there were no major complications in either group. The recurrence rate was 3.1% in the group with the balloon and 3.7 % in the group without the balloon (p = 0.8). The use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve.

Access-related complications - an analysis of 6023 consecutive laparoscopic hernia repairs

In order to investigate incidence rates and types of access-related complications that may occur during laparoscopic hernioplasty, we carried out a systematic analysis of our collected results. The aim was to identify risk factors and to develop useful modifications of the surgical technique and the instrumentation used. Since we first introduced laparoscopic hernioplasty in our clinic, we have carried out standardised, prospective documentation of relevant data from all consecutive operations in an electronic database. We performed a systematic analysis of access-related complications and their possible influencing factors, taking into special account the type of instruments used, port-site and prior intra-abdominal operations. Between April 1993 and March 2000, 4857 consecutive patients received a total of 6023 laparoscopic hernia repairs. In 510 patients three-edged, sharp trocars were used and in 4347 patients conical obturators were used to insert the port. The incidence of access-related complications was 0.9% (44/4857) in the total collection (incision hernias 0.5%, bleeding from abdominal-wall vessels 0.2%, bowel injury 0.06%, wound infections 0.06%). Injuries to intra-abdominal or retroperitoneal vessels were not observed. A differentiated analysis of the various trocar types, taking into consideration the number of inserted ports, showed that for incisions outside the linea alba the incidence of bleeding from abdominal-wall vessels was 12 times higher (0.7%, 7/1020 versus 0.06%, 5/8694). The incidence of incision hernias increased significantly (1.2%, 12/1020 versus 0.02%, 2/8694; p = 0.03) when three-edged trocars were used, as opposed to conical obturators. Our results demonstrate that, outside the linea alba, three-edged trocars should no longer be used for portinsertion. The results of our differentiated analysis of laparoscopic hernia repairs, taking into account the type of obturator, the port-site and number of ports inserted, also can be applied to other laparoscopic operations.

Determining the status of laparoscopic surgery in East Brandenburg. Results of a survey

In October 1998 the surgical hospitals of Eastern Brandenburg have been questioned about the level of laparoscopic surgery. The datas of 14 hospitals were summarized. 14% of 20.574 general surgical operations done in 1998 were performed laparoscopically. Three procedures--laparoscopic cholecystectomy, hernioplasty and appendectomy--comprised 98% of the laparoscopic operations. Laparoscopic cholecystectomy was the standard procedure for treatment of symptomatic gallstones in all hospitals. 83% of the cholecystectomies were performed by minimal invasive technique. The laparoscopic inguinal hernia repair was done in 10 of 14 hospitals. 30% of the inguinal hernias were operated by the laparoscopic method. The TAPP was the favorite operating procedure. For treatment of recurrent hernias the "tension free technique" was used in 12 of 14 hospitals. The implantation of a net is done equally by Lichtenstein's-repair and laparoscopically. Laparoscopic appendectomy has not been accepted as routine operating method. 83% of appendectomies were performed conventionally.