Laparoscopic Total Extraperitoneal Inguinal Hernia Research Articles

Laparoscopic and Open Inguinal Hernia Repair With Alloplastic Material

Management with alloplastic materials has become the standard procedure in inguinal hernia surgery. The aim of this study was to evaluate the long-term results after laparoscopic and open groin hernia repair with alloplastic material in a large patient population. We included patients in the study who underwent elective laparoscopic total extraperitoneal (TEP) inguinal hernia repair or Lichtenstein surgery between January 1998 and December 2004 for either unilateral or bilateral inguinal hernia. Patient data were recorded by a prospective online data recording system and evaluated after a minimum follow-up time of 12 (12 to 103) months by standardized questionnaires. Both objective (chronic pain, chronic dysesthesia, recurrence, and postoperative recovery) and subjective (cosmetic result, scar formation, and the choice of surgical procedure) parameters were surveyed. Seven hundred eighty-two patients with 923 inguinal hernias underwent surgery in the study period. Five hundred fifty-three patients returned the questionnaire; 62 died during the follow-up. In the remaining 491 patients, TEP was used in 292 patients (375 hernias) and the Lichtenstein procedure in 199 patients (206 hernias). TEP was significantly superior to the Lichtenstein procedure for 2 objective parameters: chronic dysesthesia and return to normal work. Regarding the subjective parameters, TEP was superior in the cosmetic results and the choice of surgical procedure. 3.1% of the patients after TEP versus 8.5% after Lichtenstein were dissatisfied with the cosmetic result (P=0.008). If secondary inguinal hernia surgery were required, 89.4% of the patients would choose TEP again versus 76.1% the Lichtenstein procedure (P<0.001). Whereas the Lichtenstein procedure was not significantly better in any of the evaluated parameters, TEP was superior especially in the subjective parameters.

Laparoscopic Total Extraperitoneal Inguinal Hernia Repair Under Spinal Anesthesia: A Study of 480 Patients

Laparoscopic total extraperitoneal inguinal hernia repair (TEP) is conventionally performed under general anesthesia (GA), and regional anesthesia is usually preferred in patients where GA is contraindicated. In this paper, we present our experience of over 8 years of using spinal anesthesia (SA) as the first choice with the contention that it is a better alternative to GA. SA was used in 480 patients over the last 8 years, and 464 patients underwent unilateral TEP. Strangulated and obstructed hernia patients were excluded, but irreducible hernia patients were included. Sedation was given if required, and the conversion to GA was done in patients not responding to sedation or with failure of SA. Comparative control included TEP performed under GA in our initial 49 patients. Three (0.63%) patients required a conversion to GA. Hypotension requiring support was recorded in 75 (15.63%) patients. Postoperatively, 2.08% (10) patients had vomiting, as compared to 30.61% (15 patients) in patients administered GA. In all, 35.83% (172) of patients required injectable diclofenac for their abdominal pain within 2 hours postoperatively, and oral analgesic was required in 301 (62.71%) patients within the first 24 hours, while 89.80% (44) patients operated an under GA required injectable analgesics in the immediate postoperative period and subsequent oral analgesia request was the same as in patients with SA. Postural headache, persisting for an average of 2.6 days, was seen in 25 (5.21%) patients postoperatively. Average time to discharge was 2.3 days. Kernofsky's performance status showed a 98.6% satisfaction level in patients. TEP done under SA has a number of advantages over GA and should be used routinely.

Laparoscopic Total Extraperitoneal (TEP) Inguinal Hernia Repair Under Epidural Anesthesia: A Detailed Evaluation

After reading the article, Laparoscopic Total Extraperitoneal (TEP) Inguinal Hernia Repair Under Epidural Anesthesia: A Detailed Evaluation, by Lal et al. [3], we have a few comments and suggestions about the techniques they practice. At our institution, we perform surgical procedures such as off-pump coronary artery bypass surgery, upper abdominal surgeries, and laparoscopic surgeries with the patient under thoracic epidural anesthesia (TEA). We have performed more than 2,000 cardiac surgeries with concomitant use of TEA [2]. We also have performed cardiac surgeries using TEA as the sole anesthetic [1]. In recent months, we have performed a few laparoscopic procedures including cholecystectomy and diagnostic laparoscopy (without endotracheal intubation). We share our experience performing laparoscopic procedures with the patient under TEA. As mentioned rightly by the authors, a block from T6 to L5 is necessary. To achieve a large block via a lumbar epidural procedure, large doses of a local anesthetic agent are required, exposing the patient to the possible hazard of its toxicity. The authors do not mention the quantity of the local anesthetic used to achieve this block. We usually insert a catheter at the thoracic 8 or 9 level. We achieve the required block initially by administering approximately 6 to 8 ml of the said local anesthetic and set up an infusion of the same local anesthetic at a rate of 5 ml/h. Because of the epidural catheter’s proximity to the zone of analgesia, the total amount of local anesthetic we use for a 2-h surgery is about 12 to 15 ml of 0.5% bupivacaine. We are of the opinion that a continuous infusion of local anesthetic is necessary to prevent inadvertent muscle recovery, which makes working conditions suboptimal for the operating surgeon and sometimes may be a cause for conversion to general anesthesia. In our experience, shoulder tip pain seems to be one of the unmanageable hassles during awake laparoscopic surgeries. Unfortunately, the authors do not suggest management of this issue. We have a few suggestions, which include spraying 0.06% bupivacaine on the peritoneum over the diaphragm via one of the ports and ‘‘painting’’ the diaphragm with a gauze piece soaked in the same concentration of bupivacaine. By these maneuvers, the pain can be alleviated to some extent. In our view, shoulder tip pain becomes a cause for conversion to general anesthesia. From our experience of awake cardiac surgical practice, we have learned that a transparent mask can be strapped onto the patient’s face by a harness. This allows us to assess and assist the patient’s ventilation. At times, after insufflation of the peritoneum with carbon dioxide, a few patients experience dyspnea. Administration of continuous positive pressure ventilation may optimize ventilatory parameters (tidal volume and end-tidal carbon dioxide). Application of this mask helps us measure end-tidal carbon dioxide. Some laparoscopic surgeons wish to use a nasogastric tube in situ. It may be prudent to pass it well in advance of surgery rather than to insert it on the operating table. Ultimately, it is needless to mention that the operating surgeon should be able to adapt himor herself to the consequences of spontaneous respiratory movements. We are of the opinion that this technique is not for novices (Fig. 1). M. C. M. Bhat (&) Department of Minimal Access Surgery, Wockhardt Hospitals, Bangalore, India e-mail: chakravarthy@gmail.com

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair under epidural anesthesia: a detailed evaluation

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is as efficacious as the open Lichtenstein procedure, can be learned with proper training, and causes less postoperative pain, better cosmesis, and earlier return to work. The one major factor preventing the widespread acceptance of TEP is the requirement for general anesthesia (GA). In contrast, open hernia is performed using local or regional anesthesia, thereby having the advantage of quicker recovery, decreased postoperative nausea and vomiting (PONV), fewer hemodyanamic changes, reduced metabolic responses to surgical stress, and better muscle relaxation. This study attempted to evaluate whether laparoscopic TEP can be performed under less invasive anesthesia, such as regional anesthesia, and to determine its feasibility and limitations All total of 22 male patients were studied between January 2002 and March 2003 in a tertiary care referral hospital. Epidural anesthesia with 2% lignocaine with adrenaline (Adr) was given via a lumbar epidural catheter, achieving a sensory level of T6. The standard technique for TEP was followed, using three midline infraumbilical ports. Twenty-two patients (20 unilateral, 2 bilateral) underwent operation. The mean operating time was 67.8 +/- 18 (range, 40-110) min. All 22 cases were started with epidural anesthesia, 7 of which (31.9%) were converted to GA; the other 15 (68.1%) were completed under epidural anesthesia. All cases were successfully completed laparoscopically, and there were no conversions. There were no intraoperative complications. There was no significant difference between the cases conducted under epidural anesthesia (67.6 +/- 23 min) and those converted to GA (69.3 +/- 7.3 min). There was no statistically significant difference between the conversion rates of smaller versus larger hernias in this study (p value 0.22). A significant association of success of the procedure was seen with a sensory level of T6 and above (2/15 conversions to GA; i.e., 13.3%) and cases with a sensory level below T6 (5/7 converted; i.e., 71.4%) and adequate epidural catheter length (p = 0.015). Prevention and management of pneumoperitoneum and subsequent shoulder-tip pain was the key to preventing conversions (6 of 9 converted to GA; i.e., 67%; p = 0.006). There were no significant postoperative complications, and no recurrences were noted during a mean follow-up period of 29 months (range, 20-36 months). From the present study it is clear that TEP is possible under epidural anesthesia provided a minimal sensory level of T6 is achieved. To achieve that level, an appropriate higher site for catheter insertion and/or adequate intraepidural catheter length needs specific attention. Pneumoperitoneum, shoulder-tip pain, intraoperative straining, and inadequate preperitoneal space are factors whose interplay leads to conversion to GA. The size of the hernia is not related to pneumoperitoneum or conversion to GA.

Less chronic pain following mesh fixation using a fibrin sealant in TEP inguinal hernia repair

Endoscopic hernia repair methods have become increasingly popular over the past 15 years. The postulated main advantages of the endoscopic technique are less postoperative pain, early recovery and lower recurrence rates. Fixation of the endoscopic mesh seems to be necessary to minimize the risk of recurrence. Stapling has been implicated to cause chronic inguinal pain syndromes. We performed a retrospective study on male patients who were endoscopically operated on primary inguinal hernias. Our aim was to clarify whether mesh fixation using a fibrin sealant is as safe and reliable as conventional stapling. Additionally, we compared the prevalence of chronic inguinal pain. A standardized population of 133 male patients (mean age 55.9 years) with 186 (80 unilateral; 53 bilateral) consecutive primary laparoscopic total extraperitoneal inguinal hernia repairs was assigned to two groups, depending on whether stapling or a fibrin sealant had been used for mesh fixation. A retrospective case control study was performed to conduct statistical analysis based on the following parameters: recurrence, complications, chronic inguinal pain, foreign body sensation and numbness. Hernia repairs numbering 173 (staples n=87; fibrin n=86) were followed up for a mean duration of 23.7 (11-47) months. The prevalence of chronic inguinal pain was significantly (P=0.002; Fisher exact test) higher in the stapled group-20.7% than in the fibrin sealant group with a prevalence of 4.7%. In terms of recurrence rate, complications and foreign body sensation, fewer patients were affected in the fibrin group than in the reference population, although the differences were not statistically significant. There were no major complications in either of the groups. The mean postoperative stay in hospital was 1.4 days. Fibrin sealing is as effective as stapling in providing secure mesh fixation. The fibrin group displayed a statistically significant lower prevalence of chronic pain syndromes. Mesh sealing provides adequate fixation and reduces the risk of chronic inguinal pain as a complication of the intervention.