Laparoscopic Herniorrhaphy Research Articles

Mesh Fixation with the Helical Fastener in Laparoscopic Herniorrhaphy: Initial Results

In laparoscopic herniorrhaphy, an alternative to mesh fixation with a stapler is now offered by the helical fastener. The helical fastener was used in 46 patients (39 men and 7 women) with 30 unilateral and 15 bilateral inguinal hernias and 1 femoral hernia. We also used a 5-mm optical system, with which we were able to reduce the size of the trocar incisions. Two 5-mm incisions and one 7-mm incision were used. The fixation elements could easily penetrate bone; therefore, the mesh was easily fixed in the public bone. Laterally, the mesh was fixed in the iliopubic tract. The peritoneum was closed by continuous, extracorporeal knotted sutures. Complications included a wound hematoma in two cases and a small bowel obstruction secondary to inadequate closure of the peritoneum in another case. This was treated by the laparoscopic technique, and the peritoneum was closed with staples. All patients were available for follow-up after 6 to 12 months and were free of recurrence at that time. Patients started to stress the groin after 2 weeks (range 1 to 3). In view of the 40% reduction in incision size and the greater stability of mesh fixation, we prefer the helical fastener over stapler fixation.

Laparoscopic Treatment of Recurrent Inguinal Hernias: Experience from 281 Operations

The results of laparoscopic repair of 281 recurrent inguinal hernias in 260 patients are presented. One hundred sixty-eight totally extraperitoneal (TEP) and 113 transabdominal preperitoneal (TAPP) procedures were performed. Four major complications occurred in the early postoperative period, three of them in the TAPP group. After 2-4 years, the results were controlled by questionnaires and clinical reexaminations, if necessary. Eleven percent of the TAPP patients and 2% of the TEP patients experienced a recurrence. About 20% of the patients reported occasional discomfort and pain in the operated groin. We conclude that laparoscopic herniorrhaphy provides acceptable results in reoperative hernia surgery.

Static Calculations for Mesh Fixation by Intraabdominal Pressure in Laparoscopic Extraperitoneal Herniorrhaphy

In laparoscopic extraperitoneal herniorrhaphy, there have been no static calculations for nonfixed prostheses with regard to the ideal size of the prosthesis, mesh overlap on the hernial orifice, friction coefficient, and shear forces. The aim of the present study was to perform these static analyses. The friction coefficient of a polypropylene mesh was measured in an experimental setting. Based on the distribution of adhesive force and load on the mesh, we calculated the required mesh overlap over the hernial opening. The friction coefficient was determined as mu0 = 0.3. The friction surface required to immobilize the prosthesis is 4.16 times the stress surface. Assuming a safety factor of 2.5, the minimum distance between the margin of the prosthesis and that of the hernial opening should be equal to the diameter of the hernial opening. For smaller lesions we recommend a minimum mesh overlap of 2 cm over the hernial orifice. From a hernia size 2 cm and larger, the distance between the margin of the prosthesis and the hernial opening should be equal to the diameter of the orifice. From 4 cm and larger, the prosthesis should be secured with a stapler (or a similar mode of fixation) to prevent recurrence.

LAPAROSCOPIC ADHESIOLYSIS FOR POSTOPERATIVE ADHESIVE ILEUS

We conducted laparoscopic adhesiolysis in 20 cases: 6 gastrectomies, 3 large intestine resectios. 2 small intestine resections, 3 appendectomies, 3 gynecological surgeries, and 1 each cholecystectomy, laparoscopic herniorrhaphy, and ventriculoperitoneal shunt.Laparoscopic adhesiolysis was successful in 19 cases. One mini-laparotomy was required in a case that had developed stenosis from firm adhesions of the small intestine, and which were resected after the minilapa-rotory. With laparoscopic surgery, it may be difficult to abrade intestinal adhesions. However, mini-laparotomy was used to deal with this situation. No complications resulting from the procedures were ob-served in any of the 20 cases. Laparoscopic adhesiolysis requires shorter postoperative hospitalization and produces fewer chances of postperative ileus.Laparoscopic adhesiolysis for adhesive ileus and intestinal adhesion features less invasive surgery and in an effective treatment.

LAPAROSCOPIC REPAIR AND GROIN HERNIA SURGERY

Over the past 15 years, laparoscopic herniorrhaphy has made the transition from an experimental to a proven procedure. With increasing laparoscopic skills in the surgical community, many surgeons are now faced with the question of when to recommend laparoscopic herniorrhaphy to their patients. A surgeon's best hernia repair is the one with which they have had the greatest experience. This results in the lowest recurrence and complication rate in his or her hands. Certainly, simple, unilateral hernias and bilateral hernias can be repaired with either anterior or laparoscopic techniques. Many times, laparoscopic herniorrhaphy is too much surgery for a young patient with a unilateral hernia. In such a case, repair is best performed with the patient under local anesthesia. Also, young patients in whom it is advantageous to avoid mesh should not undergo laparoscopic herniorrhaphy. The authors prefer laparoscopic TEP herniorrhaphy in patients with recurrent hernias, bilateral hernias, and unilateral hernias with a suspected contralateral hernia. There is also a consensus that patients with multiple recurrent hernias in whom a preperitoneal repair is appropriate are best served with a laparoscopic repair. Surgeons without advanced laparoscopic skills or without the time to develop the skills necessary to perform laparoscopic herniorrhaphy should consider referring patients with recurrent hernias to surgeons with experience in TEP. TEP is preferable to TAPP because of its lower complication and recurrence rates and in the authors' hands is the "best repair." TAPP should be reserved for patients with prior lower abdominal wall incisions that make the dissection of the peritoneum from the underside of the incision impossible. Patients who cannot tolerate general anesthesia or who have had extensive lower abdominal surgery should not undergo laparoscopic herniorrhaphy. Complication and recurrence rates, although initially higher than traditional repairs, have now fallen to equal or lower levels at centers experienced in laparoscopic techniques. Prospective randomized trials prove that when patients are selected properly and surgeons are adequately trained and proctored, laparoscopic herniorrhaphy can be performed with acceptably low incidences of recurrence and complications.

A suggested method for laparoscopic herniorrhaphy resident training

The learning curve for laparoscopic herniorrhaphy (LH) is relatively long. Resident training is ideal for the acquisition of operative skills and yet intensive feedback is necessary for more complex procedures. A method whereby faculty provide objective and specific feedback for the technical details of operative LH is described. First a pretest focusing on important aspects of LH and relevant anatomy is given to the resident the day prior to the procedure. Immediately following the operation, the faculty and resident complete an evaluation form together to stimulate discussion and provide constructive feedback. This method of teaching is especially applicable at the resident training level but can be utilized by postgraduate surgeons willing to undergo the criticisms associated with objective operative feedback. Instant operative feedback is beneficial for all including the faculty member who by necessity is forced to communicate in specific terms the operative steps leading to the safe and effective conduct of LH.

Overview of nonrandomized studies of laparoscopic hernia repair.

Laparoscopic techniques have become established in the field of general surgery. Whereas there is general agreement that laparoscopic cholecystectomy has advantages over the open surgical operation, laparoscopic herniorrhaphy or hernioplasty remains controversial. This report looks at a representation of the available literature to date concentrating on nonrandomized studies.

Laparoscopic inguinal anatomy

Irrespective of the merits of laparoscopic herniorrhaphy, the anatomy of this surgical approach is poorly understood by most surgeons. To describe and document the normal analtomy and its variations, the inguinal region was dissected from peritoneum outward by the open method in 70 cadaveric sides and by the closed laparoscopic method in 28 cadaveric sides. In our results we describe the various layers, fossae, spaces and their contents. The data presented include variations of nerves in the inguinal area and measurements of bony landmarks from important neurovascular elements. In 74%, the distance from anterior superior iliac spine (ASIS) to pubic tubercle (PT) was 11 cm (10.0–14.0); in 56% ASIS to external iliac vessels was 6 cm (4.5–7.5 cm); ASIS to femoral nerve in 64% was 5 cm (3.0–7.5). The lateral femoral cutaneous nerve was found 1–4.5 cm medial to ASIS in 15%, increasing the possibility of nerve injury. In 25.5% the ilioinguinal nerve ran through the iliac fossa, in some cases passing through the iliopubic tract. In 18% the lateral femoral cutaneous and ilioinguinal nerves were combined, and in 7.7% the ilioinguinal and genitofemoral nerves were combined. It is critical for laparoscopic surgeons to be aware of the normal inguinal anatomy and its variants to avoid unnecessary injury and pain. It is important to remember that in approximately 30% of cases, the laparoscopic anatomy of one side will not be a mirror image of the other side.

Mesh inguinodynia: a new clinical syndrome after inguinal herniorrhaphy?

Background: Chronic inguinodynia or neuralgia after conventional inguinal herniorrhaphy is rare, and diagnosing the exact cause is difficult. Treatment has ranged from local injection to remedial surgery with variable results. The increasing popularity of prosthetic mesh repairs (tension free, plug, or laparoscopic) has not eliminated these pain syndromes from occasionally occurring. Recommended management in these situations is extremely difficult. Study Design: Since 1994, 117 inguinal reexplorations have been performed for inguinodynia and 20 of these patients had primary mesh herniorrhaphy. All 20 patients had mesh removal. Records were reviewed and patients contacted to evaluate outcomes. Results: All 20 patients were evaluated (15 by telephone or direct contact, 5 by chart review). Three patients had their initial repair performed laparoscopically. Symptoms persisted for 12.2 ± 1.7 months before remedial surgery. Four patients underwent inguinal reexploration and mesh removal; 16 had mesh removal plus ilioinguinal or iliohypogastric neurectomy. Good to excellent results were achieved in 12 out of 20 patients (60%). Average followup time was 15.9 ± 3.1 months. Two of 3 patients who had laparoscopic herniorrhaphy had favorable outcomes (67%). Ten of the 16 patients who had mesh removal plus neurectomy reported good to excellent results (62%) compared with 2 of 4 reporting the same with mesh excision only (50%). Eleven patients had pain relief with preoperative nerve block. Of these, 9 had elective neurectomy resulting in good to excellent results in 5 (56%). Conclusions: Remedial inguinal exploration and mesh removal with or without neurectomy resulted in favorable outcomes in 60% of patients with mesh herniorrhaphy chronic inguinodynia (neuralgia). It appears that coincident neurectomy affords better results than mesh removal alone. Relief with nerve block did not predict favorable outcomes. Despite the popularity and favorable outcomes of prosthetic mesh repairs, persistent postoperative pain still occurs in a small cohort of patients. This may become more evident with the rising interest in laparoscopy. Correcting this problem once presented can be a formidable task. Remedial inguinal surgery with mesh removal and neurectomy will cure selected patients.

Laparoscopic herniorrhaphy in girls

Background/Purpose: Laparoscopy has been used to evaluate the contralateral side in inguinal hernias. Once a hernia was identified in such procedures, laparoscopy was terminated and a conventional groin exploration was undertaken. This study presents a purely laparoscopic approach using miniature instruments without the use of a groin incision. Methods: The technique was applied in 14 girls (median age, 6.5 years). The laparoscope was inserted via the umbilicus. Two 1.7- or 2-mm instruments were advanced (without a trocar) trough the abdominal wall for intraabdominal suturing of the open inguinal rings by the placement of two to three Z-sutures. Results: With this procedure the diagnosis is easy, although the placing of miniature suturing needs practice. When there is doubt about an inguinal ring during laparoscopy, an open processus vaginalis also can be sutured using the same approach. There were no recurrences or complications. The longest follow-up period is 1 year. Conclusions: A purely laparoscopic approach using miniature instruments combines diagnosis and immediate treatment without the need for conversion to another technique. There is rapid recovery and excellent cosmetic results.

A new method of peritoneal closure following laparoscopic herniorrhaphy.

Of the three most commonly used methods of repairing inguinal hernias laparoscopically, we believe that the transabdominal (TAPP) approach is the most effective. To perform this technique successfully, complete closure of the peritoneum is recommended to avoid the formation of postoperative adhesions. Here we describe a technique that employs the Endo Stitch instrument, facilitating easier closure of the peritoneum.

Laparoscopic Transperitoneal versus Extraperitoneal Inguinal Hernia Repair: a Prospective Clinical Trial

A prospective series of 106 inguinal hernias in 91 patients is studied, comparing two methods of laparoscopic hernia repair: a transperitoneal technique with preperitoneal stapled mesh fixation (TransAbdominal PrePeritoneal or TAPP-technique) performed in 33 patients, and a totally extraperitoneal placement of non stapled mesh (Totally ExtraPeritoneal Approach or TEPA-technique) performed in 58 patients. Conversions to open repair were equally frequent (5% vs. 7% respectively) and were due to adhesions, haemorrhage, irreducible intestinal loop in the hernial sac or important subcutaneous emphysema. Minor postoperative complications included regional seroma or haematoma, testicular pain and meralgia paraesthetica. There was no mortality nor long lasting complication. Recurrence rates in both groups amounted 2.7% (TAPP) and 2.8% (TEPA) respectively after a mean follow-up of 15.8 months (TAPP) and 17.6 months (TEPA). In both groups early recovery of normal activities was noted, after a mean of respectively 13.6 days (TAPP) and 12.9 days (TEPA). It is concluded that the transabdominal route and the totally extraperitoneal approach for laparoscopic herniorrhaphy are both adequate techniques for inguinal hernia repair with similar complication and short-term recurrence rates.

Laparoscopic herniorrhaphy: review of complications and recurrence.

Laparoscopic hernia repair has evolved considerably since its introduction. Different methods have been described, and multiple studies have been performed reporting widely varying outcomes. This study was undertaken to review all the major publications on laparoscopic herniorrhaphy from 1993 to 1996 and evaluate the rates of recurrence and complications involved in the various techniques. In a total of 11,222 laparoscopic hernia repairs, the procedure performed most frequently was the transabdominal preperitoneal patch (TAPP), followed by the total extraperitoneal patch (TEP). There were 300 (2.7%) recurrences. From 9,955 hernia repairs, there were 1,534 (15.4%) complications. Hematoma/seroma (456), neuralgia (199), urinary retention (150), and chronic pain (39) were the most frequently reported complications. Laparoscopic herniorrhaphy is a higher effective method of hernia repair with results comparable with the open technique. TAPP is still the most widely performed technique. TEP is becoming more popular, mainly because of its excellent outcome. The major drawback of TEP is the difficulty of reproducibility by different general surgeons with comparable results. Other techniques such as plug and patch carry a high rate of recurrence and complications and should probably be completely abandoned.

Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic.

The authors provide an assessment of mechanisms leading to hernia recurrence after laparoscopic and traditional preperitoneal herniorrhaphy to allow surgeons using either technique to achieve better results. The laparoscopic and traditional preperitoneal approaches to hernia repair are analogous in principle and outcome and have experienced a similar evolution over different time frames. The recurrence rate after preperitoneal herniorrhaphy should be low (< 2%) to be considered a viable alternative to the most successful methods of conventional herniorrhaphy. Experienced surgeons supply specifics regarding the mechanisms of recurrence and technical measures to avoid hernia recurrence when using the preperitoneal prosthetic repair. Videotapes of laparoscopic herniorrhaphy in 13 patients who subsequently experienced a recurrence also are used to determine technical causes of recurrence. Factors leading to recurrence include surgeon inexperience, inadequate dissection, insufficient prosthesis size, insufficient prosthesis overlap of hernia defects, improper fixation, prosthesis folding or twisting, missed hernias, or mesh lifting secondary to hematoma formation. The predominant factor in successful preperitoneal hernia repair is adequate dissection with complete exposure and coverage of all potential groin hernia sites. Hematoma mesh lifting and inadequate lateral inferior and medial inferior mesh fixation represent the most common causes of recurrence for surgeons experienced in traditional or laparoscopic preperitoneal hernia repair.

Balloon dissection of the space of Bogros via the femoral canal for total extraperitoneal laparoscopic herniorrhaphy

To obviate the need for general anesthesia or dissection of the rectus sheath, we have transferred laparoscopic herniorrhaphy back to the groin by first dissecting the suprainguinal parietoperitoneal space of Bogros via the femoral canal. Cadaver dissections demonstrated that the preperitoneal plane could be routinely fingered and distended with a digitally placed balloon introduced through a 1-cm incision immediately below the inguinal ligament. A 10-mm femoral laparoscopic port was then inserted and pressurized, allowing two standard 5-mm ports to be introduced from above, through the lower quadrant, under vision. The procedure was then carried out in the usual way, the mesh being inserted from below. Ten patients (two women), 23-73 years old, selected because general anesthesia was inadvisable, underwent uncomplicated prosthetic repair of unilateral (eight) or bilateral (two) inguinal defects. Half of the peritoneal sacs were pushed up and out of the inguinal canal; 18 months later there were no recurrences (inguinal or femoral). Preliminary experience with this new technique is promising. It may prove applicable to retroperitoneal exposure of the distal aorta and iliac vessels, allowing laparoscopic bypass for Leriche syndrome.

Does Hypercarbia Develop Faster During Laparoscopic Herniorrhaphy than During Laparoscopic Cholecystectomy? Assessment with Continuous Blood Gas Monitoring

Does Hypercarbia Develop Faster During Laparoscopic Herniorrhaphy than During Laparoscopic Cholecystectomy? Assessment with Continuous Blood Gas Monitoring

LAPAROSCOPIC HERNIORRHAPHY

There is little doubt that laparoscopic herniorrhaphy has assumed a place in the pantheon of hernia repair. There is also little doubt that further work needs to be done to determine the exact role that laparoscopic hernia repair should play in the surgical armamentarium. Hernias have been surgically treated since the early Greeks. In contrast, laparoscopic hernia repair has a history of only 6 years. Even within that short time, laparoscopic hernia repair techniques have not remained unchanged. This is obviously a technique in evolution, as indicated by the abandonment of early repairs ("plug and mesh" and IPOM) and the gradual gain in pre-eminence of the TEP repair. During the same time frame, surgery itself has evolved into a discipline more concerned with cost-effectiveness, outcomes, and "consumer acceptance." Confluence of these two developments has led to a situation in which traditional concerns regarding surgical procedures (i.e., recurrence rates or complication rates) assume less of a role than cost-effectiveness, learnability, marketability, and medical-legal considerations. No surgeon, whether practicing in a academic setting or a private practice, is exempt from these pressures. Laparoscopic hernia repair therefore seems to fit into a very specialized niche. In our community, the majority of general surgeons are only too happy to not do laparoscopic hernia repairs. On the other hand, in our experience, certain indications do seem to cry out for a laparoscopic approach. At our own center we have found that laparoscopic repairs can indeed be effective, and even cost-effective, under specific circumstances. These include completing a minimal learning curve, utilizing the properitoneal approach, minimizing the use of reusable instruments, using dissecting balloons as a time-saving device, and very specific patient selection criteria. At present these include patients with bilateral inguinal hernias on clinical examination, patients with recurrent unilateral or bilateral hernias, and patients who, because of economic pressures, must return to work within 10 days of surgery. Within these limitations we feel that the laparoscopic approach definitely has a place in repair of inguinal hernias. In the future new techniques, decreased equipment costs, and the ability to use local anesthesia may increase the applicability of laparoscopic herniorrhaphy.

A randomized controlled trial of laparoscopic extraperitoneal hernia repair as a day surgical procedure

A randomized controlled trial was conducted in a day surgery setting comparing a standardized variant of the Shouldice hernioplasty with extraperitoneal laparoscopic herniorrhaphy. The laparoscopic repair was technically challenging, evidenced by conversion from extraperitoneal to transabdominal repairs in 6.25% of patients. It was free from the inherent dangers of intraperitoneal laparoscopy. Surgical morbidity was low and comparable to that for patients randomized to the open repair. Outcome following laparoscopic extraperitoneal herniorrhaphy varied depending on the parameter measured. It was comparable to the open repair with respect to postoperative activity levels and the number of days required for return to work but inferior to the open repair in terms of operation time and time to hospital discharge. The extraperitoneal approach was superior to the open repair with respect to postoperative pain levels and analgesic requirements. No attempt was made to compare recurrence rates due to the short follow-up period. Laparoscopic extraperitoneal herniorrhaphy should not supercede conventional hernia repair until subjected to further trials with the aid of larger study populations and greater technical expertise; the results of long-term recurrence rates are awaited.

Laparoscopic herniorrhaphy. Diagnostic and therapeutic technology assessment

To provide clinicians with a technology assessment of the safety and effectiveness of laparoscopic herniorrhaphy for the surgical repair of inguinal hernias.A literature review and a Diagnostic and Therapeutic Technology Assessment (DATTA) survey questionnaire were mailed to 75 physicians with expertise in surgical repair of inguinal hernias. These panelists had been nominated to the DATTA panel by the appropriate specialty societies and medical schools. A total of 55 panelists (73%) responded.Assessment was based on the expert opinion of the panelists, as well as on published literature (available as of February 8, 1996). Published studies were identified by a MEDLINE search using the terms laparoscopic surgery, inguinal hernia, and laparoscopic herniorrhaphy and by review of the references cited in these primary sources.The respondents completed a DATTA survey questionnaire; the survey results were tabulated, analyzed, and interpreted by American Medical Association staff.The DATTA panelists rated the use of laparoscopic herniorrhaphy as promising for safety and investigational for effectiveness for two indications: the repair of primary inguinal hernias and the repair of bilateral inguinal hernias. The use of laparoscopic herniorrhaphy to repair recurrent inguinal hernias was rated as investigational for both safety and effectiveness by the panel. This technique was rated as promising for safety and effectiveness as a method for decreasing postoperative tenderness and time until return to full activity.

Laparoscopic Herniorrhaphy

Objective. —To provide clinicians with a technology assessment of the safety and effectiveness of laparoscopic herniorrhaphy for the surgical repair of inguinal hernias. Participants. —A literature review and a Diagnostic and Therapeutic Technology Assessment (DATTA) survey questionnaire were mailed to 75 physicians with expertise in surgical repair of inguinal hernias. These panelists had been nominated to the DATTA panel by the appropriate specialty societies and medical schools. A total of 55 panelists (73%) responded. Evidence. —Assessment was based on the expert opinion of the panelists, as well as on published literature (available as of February 8,1996). Published studies were identified by a MEDLINE search using the terms laparoscopic surgery, inguinal hernia , and laparoscopic herniorrhaphy and by review of the references cited in these primary sources. Consensus Process. —The respondents completed a DATTA survey questionnaire; the survey results were tabulated, analyzed, and interpreted by American Medical Association staff. Conclusions. —The DATTA panelists rated the use of laparoscopic herniorrhaphy as promising for safety and investigational for effectiveness for two indications: the repair of primary inguinal hernias and the repair of bilateral inguinal hernias. The use of laparoscopic herniorrhaphy to repair recurrent inguinal hernias was rated as investigational for both safety and effectiveness by the panel. This technique was rated as promising for safety and effectiveness as a method for decreasing postoperative tenderness and time until return to full activity. ( JAMA . 1996;275:1075-1082)