Laparoscopic Herniorrhaphy Research Articles

LAPAROSCOPIC INGUINAL HERNIORRHAPHY IS NOT A VALID PROCEDURE

Laparoscopic inguinal herniorrhaphy with or without application of mesh does not correct the basic problem. Unless the dense fascial and bony margins of the posterior inguinal canal wall are palpated under direct vision for suture of the mesh, fortification is not possible and recurrence is invited. The many neural structures cannot be seen with the laparoscope, and their stapling is a prominent hazard. The procedure should not be accepted or approved.

Abdominal adhesions in laparoscopic hernia repair. An experimental study.

Laparoscopic herniorrhaphy is becoming an increasingly common procedure. The possible creation of intraperitoneal adhesions during laparoscopic herniorrhaphy has not been examined. For the transperitoneal hernia repair to be an acceptable option, the hypothesis that this approach will incite significant adhesions must be rejected. To test this hypothesis, 21 pigs underwent laparoscopic herniorrhaphy using a standard procedure with the implantation of a polypropylene mesh graft on one side while a sham procedure was performed on the other. These animals were later examined laparoscopically for adhesion formation and the condition of the graft. None of the 21 animals developed adhesions to the trocar sites, 12 animals developed adhesions to the area of the polypropylene mesh, and 3 developed adhesions to the side of the sham procedure. There were no adhesions involving the small intestine. It is therefore concluded that the hypothesis should be rejected and that laparoscopic herniorrhaphy does not incite significant adhesions.

Laparoscopic herniorrhaphy. Transabdominal preperitoneal floor repair.

The purpose of this study was to evaluate the results of a laparoscopic transabdominal preperitoneal (TAPP) approach to inguinal hernia repair which dissected the entire inguinal floor and repaired the indirect, direct, and femoral areas in all patients without tension. In our series, 183 patients had 205 hernia repairs and were followed for more than 6 months. Of this group, 128 hernias were indirect, 55 direct, 22 pantaloon, 26 recurrent, and 22 bilateral. All 12 females and the first 11 males had a single-buttress repair with polypropylene mesh. The other 160 male patients had a double-buttress repair. With median follow-up of 12 months, ranging from 6 to 21 months, no recurrences were found. Patients returned to normal activity in an average of 1 week. Dissection and buttressing of the entire inguinal floor with mesh appeared to solve the problem of early recurrence first seen in laparoscopic herniorrhaphy.

Laparoscopic herniorrhaphy. A preperitoneal tension-free approach.

At the present time laparoscopic herniorrhaphy appears to be successfully performed by utilizing a preperitoneal approach. The major indications are bilaterals hernia and the recurrent hernia. Other routine hernias may be done at the decision of the surgeon and patient depending upon the necessity of rapid return to work and desire to minimize pain. Utilizing this approach, the recurrence rate at the present time is less than 1%, which compares favorably with all other types of repair.

Laparoscopic Inguinal Herniorrhaphy with Mesh: An 18-Month Experience

One-hundred-thirty-five laparoscopic inguinal hernia repairs were performed in 110 patients over an 18 month period. In all, 75 indirect, 24 direct, 23 bilateral, 5 scrotal, and 7 recurrent hernias were repaired. Types of repairs included plug only (4%), plug and patch (19%), and large stapled patch (77%). One-hundred-six patients were male. No recurrence rates were found at 6 and 12 months postoperatively. Minimal postoperative pain was noted in nearly all cases, and disability was only 4-10 days in 96% of unilateral repairs. Patients returned to immediate unrestricted duties. The operation has evolved from a simple plug repair to a large stapled patch. Ninety-seven percent of unilateral repairs were performed in less than 80 min. Repair of recurrent hernias created less morbidity by avoidance of the old incision. Scrotal hernia repair was expedited by amputating the large sac and leaving it in place. Fifty-three percent of patients required little or no analgesics. Only four significant complications occurred in this series, including an inadvertent bladder injury, one case of persistent pain requiring conversion to open repair, one other case of dyspareunia over a plug, and one case of uncontrollable bleeding requiring a groin incision. The new technique offers minimal incision, minimal pain, and minimal disability.

Lap Aroscopic Inguinal Herniorrhaphy: Techniques and Controversies

Because of the remarkable success of laparoscopic cholecystectomy, numerous investigators have attempted to duplicate this success with laparoscopic herniorrhaphy. This article presents a different view of the preperitoneal anatomy, reviews the rationale behind the various laparoscopic approaches, and presents, in detail, the laparoscopic preperitoneal repair with mesh, including complications and early recurrences. An attempt is made to put the new laparoscopic procedures into perspective with regard to economic issues and safety.

Complications of laparoscopic herniorrhaphy.

Anterior inguinal hernia repair is the second-most-commonly performed abdominal operation and has been associated with low morbidity and mortality rates. The principle of laparoscopy has been applied to this surgical problem in a series of 762 patients with 841 inguinal hernias. Four types of laparoscopic repairs were conducted: (1) high ligation of the indirect inguinal hernia sac and closure of the internal ring (87 patients with 89 hernias); (2) plug and patch of the internal ring (74 patients with 87 hernias); (3) transperitoneal suture repair of the transversalis fascia to the iliopubic tract or Cooper's ligament (28 patients with 30 hernias); and (4) placement of a large prosthesis over the myopectoneal orifice (563 patients with 635 hernias). These early results indicate that the overall complication rates were low, especially when a large prosthesis was used to reinforce the myopectoneal orifice. It is concluded that laparoscopic inguinal herniorrhaphy is a safe and effective procedure with which to manage this surgical problem.

Is Laparoscopic Herniorrhaphy an Effective Alternative to Open Hernia Repair?

While the inguinal approach to hernia repair remains the standard of care, laparoscopic hernia repair techniques are rapidly evolving. The first 102 laparoscopic hernia repairs were reviewed. Reported herein are the types of hernias repaired, length of hospital stay, early recurrence rate, complications, and assessment of postoperative pain. The long-term recurrence rate has yet to be determined. From these results, it is felt that in select patients, laparoscopic hernia repair is an effective surgical alternative in the treatment of inguinal hernia.

Double-buttress laparoscopic herniorrhaphy.

To determine if laparoscopic inguinal herniorrhaphy can be performed safely in unselected patients, the authors' first 100 consecutive laparoscopic inguinal hernia repairs were reviewed. All patients with inguinal hernias who were candidates for general anesthetic were accepted for the study. Their ages ranged from 18 to 84 years. One hundred and six hernias were laparoscopically repaired in 95 males and 4 females. One male patient required an open hernia repair. The first 14 patients were repaired with a preperitoneal patch and plug technique, and the next 85 with the double-buttress transabdominal preperitoneal approach. Two pieces of polypropylene mesh were stapled to the transversalis fascia, ileopubic tract, and Cooper's ligament after the preperitoneal dissection of the hernia was completed. The first piece was placed over the indirect space, with a slit for the cord medially, and the second piece was placed over the entire direct and indirect area. Patients have been followed from 8-18 months. To date, no recurrence has developed. Complications have included seroma, inferior epigastric bleeding, trocar hernia, and neuralgia. Patients have returned to work and normal activity in 2 days to 2 weeks, with an average of 1 week.

Laparoscopic hernia repair: A review

Three principal approaches for laparoscopic herniorrhaphy are described. The most recent results are presented and discussed. The most popular current approach is the transabdominal pre-peritoneal prosthetic repair. This method involves laparoscopic access to the peritoneal cavity, incision of the peritoneum from within to access the pre-peritoneal plane, disposition of the hernial sac, placement of the mesh in the pre-peritoneal plane, and re-approximation of the peritoneal flap to provide a barrier between the mesh and the bowel. A second laparoscopic approach is the extraperitoneal operation. This involves a small incision below the umbilicus, tunnelling to develop the pre-peritoneal space without entering the peritoneum, disposition of the hernial sac, placement of mesh and closure. This approach is more difficult for the surgeon to learn compared with the transabdominal approach. The third approach - known as the intraperitoneal onlay mesh operation - is the easiest and fastest to perform but is also...

Laparoscopic Herniorrhaphy

Laparoscopic inguinal hernia repair could represent an attractive alternative to conventional inguinal herniorrhaphy if it can be shown to result in less perioperative morbidity (primarily postoperative pain) or a decreased long-term recurrence rate. The data addressing either of these concerns will be forthcoming in ensuing years. The variations in the laparoscopic approach to the preperitoneal space and the differences in dissection and fixation techniques outlined in this article reflect the fact that the procedure is still evolving, and there is not yet a consensus on the best laparoscopic herniorrhaphy. It is likely that there will not be one laparoscopic technique applicable to all inguinal hernias. Rather, the patient's body habitus and the type of hernia encountered at laparoscopy will persuade the surgeon to use one of several techniques. Once a consensus is reached among surgeons as to the optimal laparoscopic hernia repair(s), it will be possible to begin gathering data concerning perioperative morbidity and recurrence rates. Only then can the question be answered whether laparoscopic inguinal herniorrhaphy has any advantages over the conventional extraperitoneal operation. A multicenter prospective nonrandomized trial has been initiated by our group in an attempt to determine whether laparoscopic inguinal herniorrhaphy has efficacy. The exact technique employed by the individual centers has not been strictly regulated, but general guidelines have been given. It is hoped that this project will provide information on whether laparoscopic inguinal herniorrhaphy is a useful alternative to conventional repair. Most of the laparoscopic inguinal herniorrhaphy techniques described in this article expose the patients to the inherent risks of initial laparoscopic penetration of the abdomen and the long-term possibility of adhesions to the sites where the peritoneum has been breached. Because these risks are not present in a conventional repair, the laparoscopic technique must have other advantages if it truly is to obtain a place in the armamentarium of general surgeons.

Laparoscopic Hernioplasty-Reply

<i>In Reply</i>.—Lichtenstein et al state that modern day hernioplasty is efficacious and simple, but recent reviews of hernia repairs show recurrence rates as high as 20.9%.¹The absence of recurrences in 1000 cases reported by Lichtenstein et al²has been the exception and must be attributed to the "tension free" repair. Proponents of laparoscopic herniorrhaphy use this principle to reduce recurrence. Concerns over long-term fate of intraperitoneal prosthetic material is real and formation of adhesions, erosion into adjacent structures, and infection must be a concern for any surgeon using these materials in the peritoneal cavity. The ultimate prosthetic material for intraperitoneal placement has not been developed, and surgeons should only implant these materials after careful consideration and informed consent. Another technique that may alleviate the need for intraperitoneal placement is the preperitoneal repair with prosthetic mesh. Open surgical repair using Stoppa's technique of preperitoneal prosthetic mesh placement

LAPAROSCOPIC HERNIORRHAPHY

Laparoscopic herniorrhaphy is compared with conventional herniorrhaphy in 20 patients, who underwent laparoscopic herniorrhaphy utilizing a Mersilene plug and patch graft, and high ligation of the neck of the sac with an Endo-GIA. Patients were pain-free and returned to normal activity the first postoperative day. There was one recurrent direct inguinal hernia in an indirect repair. Laparoscopic herniorrhaphy appears to be a safe, effective way to repair indirect inguinal hernias and certain direct inguinal hernias. There is a marked reduction of pain and rapid return to normal activity. The disadvantage of this procedure is the lack of long-term follow-up.

The Gazayerli Endoscopic Retractor Model 1

A simple yet effective abdominal wall retractor for use in endoscopic surgery is described. It has been used in laparoscopic herniorrhaphy, laparoscopic cholecystectomy in the morbidly obese, and lysis of abdominal wall adhesions, and to control abdominal wall bleeding.