Method For Inguinal Hernia Repair Research Articles

A Walk along the Learning Curve of Totally Extra-Peritoneal (TEP) Repair of Inguinal Hernia

Objectives/Background: Laparoscopic repair of inguinal hernia is a recent advancement gaining global popularity. It supposedly has a very steep learning curve due to various reasons. This study highlights an initial experience with totally extra-peritoneal repair of inguinal hernias with respect to difficulties, the learning curve, and outcome of this experience. Methods: It’s a prospective descriptive analysis of first 78 consecutive TEP repairs of inguinal hernias performed in 67 patients in a teaching hospital as well as private hospitals during one and a half year. Patients less than 15 years, morbidly obese, old unfit patients and patients with previous history of lower abdominal surgery, recurrent hernias, complicated and complete scrotal hernias were excluded. All the patients were explained the new technique and were informed of the likely complications and all the known benefits. Those who gave consent were registered as study subjects. Variables studied included demographics, difficulties/complications during surgery, early post-operative complications, chronic pain and recurrence of hernia. A detailed pro forma was duly filled in by one of the authors and attached with history chart of every patient. The patients were reviewed after 15 days and then every three months for a period of one year. The data collected was then statistically analyzed on SPSS version 16. Results: This study took one and a half years to complete from Jan 2009 to Jun 2010 during which we operated 67 patients with 78 primary inguinal hernias with a mean age of 40.27, Std 9.724 and a range of 38(20-58) years. All the patients were males with 56 (83.58%) unilateral and 11 (16.41%) bilateral inguinal hernia. The mean operative time of the initial 30 cases was reduced by 50% in the last cases. A number of early post-operative complications occurred during the same hospitalization. Results of three years of follow up are quite promising and encouraging. Conclusion: TEP is a safe and reliable method of inguinal hernia repair. Initial problems and fear due to a totally different anatomy soon overcome by repeated attempts at repair by this technique and sticking to the rules laid down by experts in this field.

Bilateral Endoscopic Total Extraperitoneal (TEP) Inguinal Hernia Repair Does Not Induce Obstructive Azoospermia: Data of a Retrospective and Prospective Trial

The endoscopic totally extraperitoneal (TEP) mesh repair is nowadays a well-established tension-free method for inguinal hernia repair. Mainly based on animal studies and case reports, a concern about the risk of postoperative infertility was expressed. This clinical study aimed to evaluate the risk of infertility due to obstructive azoospermia in men of fertile age who underwent a bilateral hernia repair. Over 3years (2005-2008) 59 male patients, 18-60years of age, underwent a bilateral TEP repair. Twenty-one of them were prospectively ("light mesh") and 38 retrospectively ("heavy mesh") evaluated for testicular volume and perfusion, serum levels of sexual hormones, ejaculate volume, and number of spermatic cells. Those parameters were determined preoperatively (prospective group) and not earlier than 3months postoperatively (both groups). No significant difference between pre- and postoperative values was detected in the prospectively studied group. All postoperative parameters were within the normal range in the retrospective group. There was no evidence of impaired fertility in any patient due to the operation. The standardized TEP technique for simultaneous bilateral inguinal hernia repair in male patients was not associated with a higher risk for postoperative infertility after mesh implantation. The use of heavy-weight meshes had no negative effect on fertility.

Inguinal hernia disease in Africa: a common but neglected surgical condition.

Hernia surgery is one of the most frequent procedures done by surgeons - paediatric and general surgeons -in the African continent. To review the surgical literature, on the epidemiology, clinical features, treatment and outcome of inguinal hernia surgery in Africa. The search terms used were groin hernias in Africa, hernia surgery in Africa, inguinal hernias in Africa, hernias in adults and hernias in children in Africa using Medline, Cochrane Central Register of Controlled Trials and EMBASE. All journal articles on inguinal hernias performed in Africa and published in the world journals from 1990-2010 were retrieved. All articles containing information on inguinal hernias in children and adults were carefully studied for epidemiology, clinical presentation, method of hernia repair, complications (including morbidity and mortality rates) and the future of hernia surgery in Africa. There was an absolute dearth of knowledge of the burden of inguinal hernias in the various communities in Africa, especially, in sub-Saharan Africa. There were non-existent population-based studies in the sub-Saharan context that could inform us about the epidemiology of inguinal hernias and hence estimate the necessity for surgery in Africa. The studies were all clinical in nature and did not reflect the true burden of the disease among Africans. In many of these hospital-based studies, the method of inguinal hernia repair used most was the Bassini repair. Not much was found in the literature about the use of the Lichtenstein tension-free mesh repair of inguinal hernias, the reason being that the mesh was too expensive for the patients to afford. Scarcely, was laparoscopic hernia repair mentioned. Based on the clinical studies reviewed, there is a large disease burden of inguinal hernias in Africa. There is, understandably, also a limited surgical capacity to reduce this burden. The authors advocate the formation of an African Hernia Society to partner with corporate and international organisations to make hernias a public health problem and to attempt to determine, using population-based studies, the actual burden of the disease in Africa and then to take modern hernia surgery to most parts of the continent to help reduce the hernia burden, especially its complications.

Occult hernias detected by laparoscopic totally extra-peritoneal inguinal hernia repair: a prospective study

One distinct advantage of laparoscopic inguinal hernia repair is the opportunity for clear visualization of the direct, indirect, femoral, obturator and other groin spaces. The aim of this study was to examine/assess the potential of the laparoscopic totally extraperitoneal (TEP) inguinal hernia repair method in detecting unexpected additional hernias. Patients who underwent an elective inguinal hernia repair, in the department of abdominal surgery at the institute of laparoscopic surgery (ILS, Bordeaux, France) between September 2003 and July 2005 were enrolled prospectively in the study. The patients' demographic data, operative, postoperative course and outpatient follow-up were studied. A total of 337 laparoscopic inguinal hernia repairs were performed in 263 patients. Of these, 189 patients had unilateral hernia (109 right and 80 left) and 74 patients had bilateral hernias. Indirect hernias were the most common, followed by direct and then femoral hernias. There were 218 male patients and 45 female patients with a mean age of 60 ± 15 years. There were 44 unexpected hernias: 6 spegilian hernias, 19 obturator hernias and another 19 femoral hernias. Two patients were converted to transabdominal preperitoneal (TAPP) due to surgical difficulties. There were no major intraoperative complications in all patients except for three cases of bleeding arising from the inferior epigastric artery. Only one patient had postoperative bleeding and was re-operated on several hours after the hernia repair. No recurrence occurred in the present series. The laparoscopic inguinal hernia repair approach allows viewing of the entire myopectineal orifice, facilitating repair of any unexpected hernias and thereby reducing the chance of recurrence.

Inversion Herniotomy: A Laparoscopic Technique for Female Inguinal Hernia Repair

Laparoscopic inversion herniotomy (LIH) is a method of inguinal hernia repair for female patients. In this article, we report our technique and outcomes for this procedure. We propose that LIH is a valid alternative to conventional open herniorraphy. Following institutional review board approval, we reviewed the charts of patients who underwent LIH or open inguinal hernia repair (OIH) from 2004 to 2007. LIH was performed with three instrument sites and no groin incision. The diagnosis, operative time, and complications were reviewed. Follow-up ranged from 5 months to 4 years. We performed 79 LIH repairs (15 bilateral, 23 left, and 26 right) in 63 female children. We also performed 76 contemporaneous OIH repairs in girls. The age range was 1 month to 18 years (median, 3.8 years). Operative times for both the unilateral and bilateral LIH repairs were significantly shorter than those for OIH (P = 0.001). There were 2 recurrences after laparoscopic inguinal hernia repair, both within 5 months following repair early in our experience, compared to no hernia recurrences with OIH. The first recurrence was repaired conventionally via an open technique. The second case was repaired laparoscopically. LIH is an effective method for the repair of pediatric indirect inguinal hernia in female patients. The procedure allows the evaluation of the asymptomatic contralateral side without the necessity of a second long inguinal incision.

Clinical Analysis of Inguinal Hernia in Adult Using Prolene Hernia System

Purpose: The aim of this study was to detail clinical experiences with a type of tension-free herniorrhaphy using the prolene hernia system (PHS) and analyze the system’s usefulness. Methods: We retrospectively reviewed the medical records of 122 patients who underwent an inguinal hernia repair using PHS between March 2004 and August 2008. Results: There were 116 male and 6 female patients ages 14 to 99; 79 indirect, 33 direct, 10 pantaloon hernias. The right inguinal hernias were more frequent (64.7%). The mean operative time for inguinal hernia repair using PHS was 45.2±1.5 minutes and the mean postoperative hospital stay was 3.5±1.5 days (101±82.9 hours). The most frequent combined disease was hypertension. The most frequent complication of PHS repair was hematoma. The mean number of used analgesics was 3.1±3.3. There were no postoperative recurrences. Conclusion: Tension-free herniorrhaphy using PHS is thought to be a useful method of inguinal hernia repair in adults because it offers lower postoperative pain, shorter operation time and shorter postoperative hospital stay.

A selective sac extraction method: another minimally invasive procedure for inguinal hernia repair in children: a technical innovation with satisfactory surgical and cosmetic results

Purpose To achieve satisfactory surgical and cosmetic results with minimal surgical invasiveness without laparoscopic assistance in childhood inguinal hernia repair, a novel technique, the selective sac extraction method (SSEM), was devised. The technical feasibility of this method was retrospectively examined. Methods The method was applied to 162 consecutive hernia repairs in 153 patients, 79 boys and 74 girls, excluding patients with incarcerated or irreducible hernia, sliding hernia of the ovary (hernia with palpable ovary at repair), or hernia associated with an undescended testis. Hernia repair was performed by several young surgeons under the guidance of one teaching surgeon. Results Patients' ages ranged from 1 month to 12 years (median, 3 years), and their body weights ranged from 2.9 to 41 kg (median, 14.4 kg). The SSEM was accomplished in 149 (92%) of 162 repairs, and lengths of incision at the end of the procedure were less than 10 mm in all repairs. The success rate was 72 (88%) of 82 repairs in male patients and 77 (96%) of 80 repairs in female patients. In the remaining 13 (8%) repairs in 13 patients, 10 males and 3 females, the procedure was converted to a conventional open method by extending the incision to 10 mm or longer. The ages of the 13 patients ranged from 1 month to 8 years (median, 3 months), being significantly younger than patients whose repair was accomplished by the SSEM ( P = .006). The reason for conversion in 9 repairs was a huge or thickened sac that could not be extracted from the small incision, of which 6 involved male infants younger than 11 months. Obesity (the body mass index was 22.2 and >97th percentile for the patient's age) and thick subcutaneous tissue characteristic of early infancy were also reasons, both of which hindered the approach to the inguinal canal. Other reasons included malpositioning of the skin incision and difficulty in sac identification. The lengths of incision at the end of the 162 repairs ranged from 4.5 to 13.0 mm (median, 7.0 mm). Those in female patients, 4.5 to 11.5 mm (median, 6.5 mm), were significantly shorter than in male patients, 5.0 to 13.0 mm (median, 7.5 mm) ( P < .001). The median length of the operation was 25 minutes. A follow-up interview revealed that there was no hernia recurrence with a median follow-up time of 20 months (range, 12-29 months). No postoperative complications were reported by the parents. As for the parents' satisfaction with wound cosmesis, 93% of them rated it as good or excellent. Conclusions Inguinal hernia repair with the SSEM through a minimal skin incision is technically feasible, with very satisfactory surgical and cosmetic results. As it has the potential to be a standard method for inguinal hernia repair in children, a prospective study to confirm the safety of the procedure should be carried out.

Inguinal hernia repair: the hypothesis postulated in the article is not true

Dear Editor, I read with interest the recent article of Amato et al. [1] describing a new hypothesis of inguinal hernia repair. Amato et al. stated that “Through years of surgical experience, we have seen the formation of adhesions and Wbrosis in these delicate and key structures, and hypothesised that they may impair its shuttering action, thus, creating a patency of this jammed inguinal ring leading to hernia.” This hypothesis itself is highly questionable. The adhesions and Wbrosis seen by Amato et al. in the operations performed by them are the results of hernia formation and do not precede hernia formation. They should have carried out inguinal canal dissections in normal individuals or cadavers to draw such conclusions and postulate such a hypothesis. Anson et al. [2] have performed inguinal canal dissection in 500 body-halves and clearly mentioned the detailed anatomy of aponurotic extensions from the transversus abdominis aponurotic arch (dessiduous part). The author of this letter to the editor has further highlighted the importance of this, till today neglected, structure as the basic primary factor that prevents hernia formation in normal individuals [3]. The posterior wall of the inguinal canal from the pubic tubercle to the internal ring is not formed by transversalis fascia alone as a single-layer structure, but is formed by two layers. Another layer is of those aponurotic extensions that give real protective cover. Inguinal hernia formation takes place in those individuals in whom this layer is either absent or deWcient. The strength of the posterior wall is directly proportional to the number of Wbres it contains and not to the transversalis fascia, which is papery thin [4]. Amato et al. should have given answers to many questions such as: (1) How can anybody draw new conclusions in a retrospective study? (2) Can anybody really remove all Wbrotic elements, especially when they are intra-muscular? (3) Can anybody really dilate an already dilated and patulous internal ring? (4) How could they measure the completeness of the adhesiolysis in each patient on which their hypothesis is based? (5) Do they mean that there will not be Wbrosis again? (6) Do they mean that the prosthesis inserted by them will not result in Wbrosis? (7) The results seen by them in their series are because of the prosthesis alone or because of their manoeuvre of internal ring dilatation and adhesiolysis? The author feels that “(1) meticulous adhesiolysis, (2) mechanical dilation (divulsion) of the inguinal oriWce, (3) allowing viable muscle Wbres to contract freely, (4) give a gentle outwards force to induce a reactive contraction of the sphincter-like muscle” are all imaginary without any scientiWc support. The statements in the conclusions section and elsewhere that “This circular-shaped muscular structure, concentric muscular complex” were never heard of or read by the author. Nobody gave such a description of those muscles in the past in any textbook. Amato et al. should have given evidence to such statements also. The author to this letter to the editor has already published a new method of inguinal hernia repair without mesh that is based on the physiological principle [5] and the new concepts or theories that prevent hernia formation in normal individuals [3]. The readers are requested to read both of these articles for a better understanding of the surgical anatomy and physiology of the inguinal canal. M. P. Desarda Poona Hospital and Research Centre, Pune, India

Comparison of Modified Darn Repair and Lichtenstein Repair of Primary Inguinal Hernias

This study was designed to compare the results of the Modified Darn Repair through Lichtenstein procedure in inguinal hernias. The study involved 322 patients with inguinal hernia, operated in General Surgery Departments of Gulhane Military Medical Academy and Sirnak Military Hospital between 1998 and 2004. The durations of operation time, hospitalization, and time to return to daily activities and postoperative complication and recurrence rates were evaluated. Lichtenstein procedure was applied on 170 patients (Group 1), and modified darn repair was applied on 152 patients (Group 2). The average follow-up period was 56 months. For the Lichtenstein procedure, the average duration of operation was 56 min; the average time to return to routine activities was 20 days. The number of patients with postoperative complications was 20 (11.7%), and the number of patients with recurrence was 1 (0.6%). For modified darn repair, the average duration of operation was 48 min; the time to return to daily activities was 20 days. The number of patients with postoperative complication was three (1.9%), and no recurrences were noted. The hospitalization time of the groups was similar. Modified darn repair is a reliable method for inguinal hernia repair with short hospitalization time, low rate of postoperative complications, and recurrence.

Anterior Rectus Sheath in Inguinal Hernia Repair: Preliminary Study

Inguinal hernia repair using the anterior rectus sheath flap represents a tension-free repair with potential advantages (no foreign material or tension on the suture line). The aim of this research was to evaluate the method of inguinal hernia repair using the anterior rectus sheath and to compare it with tension-free mesh repair (modified Lichtenstein repair). In total, 62 patients were evaluated. Each patient's age, gender, type of hernia, total operating-room time, the length of postoperative hospital stay, and the recurrence-free period were recorded, as well as the total number of postoperatively administered doses of analgesics, and analyzed using the Mann–Whitney test. No difference in age (p =. 08), postoperative hospital stay (p = 0.810), or postoperative use of analgesics (p =. 116) was observed between two groups. Total operating-room time was significantly longer in patients undergoing mesh repair (median 80 min, range 45–150) compared to anterior rectus sheath repair (median 65 min, range 45–125) (p =. 049). No complications or recurrences were noted in either group. Thus, this study showed good results using the anterior rectus sheath repair for primary, uncomplicated inguinal hernias, comparable to mesh repair.

Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair

Laparoscopic herniorrhaphy has emerged as a recognized operative method for inguinal hernia repair. This study compared the short-term results of two tension-free methods of repair: totally extraperitoneal (TEP) laparoscopic patch repair and the open Lichtenstein mesh technique. A total of 1513 men from 11 hospitals who presented with a primary unilateral inguinal hernia were randomized to one of the two methods. Operating time, short-term complications, reoperations, postoperative pain, consumption of analgesics, sick leave and time to resumption of normal physical activities were recorded. Some 1371 of the 1513 men underwent surgery, 665 in the TEP group and 706 in the Lichtenstein group. The median duration of operation was 55 min for both procedures and 91.0 percent of the patients in both groups were discharged on the day of operation. Patients in the TEP group experienced less postoperative pain (P<0.001), consumed fewer analgesics (P<0.001), had a shorter period of sick leave (7 versus 12 days; P<0.001) and a shorter time to resumption of normal physical activity (20 versus 31 days; P<0.001). The TEP technique took no longer to perform, and was associated with less postoperative pain, a shorter period of sick leave and a faster recovery, compared with open Lichtenstein hernia repair.

A United Kingdom survey of surgical technique and handling practice of inguinal canal structures during hernia surgery

Recent trials have assessed the impact of elective nerve division on patient outcome after inguinal herniorrhaphy. The aim of this study was to establish UK surgical practice of handling of structures in the inguinal canal during herniorrhaphy. A cross-sectional survey of all Fellows (n = 1113) of the Association of Surgeons of Great Britain and Ireland (ASGBI) was performed. The main outcomes were to determine method of inguinal hernia repair and routine practice for intra-operative handling of structures in the inguinal canal. A total of 852 (77%) questionnaires were returned, of which 784 (92%) surgeons performed inguinal herniorrhaphy. Approximately two-thirds (63%) of responding surgeons performed less than 50 procedures per annum and 37% conducted more than 50 procedures annually. Mesh was the preferred method used by 90% of surgeons; 6% used non-mesh, and 4% used other (laparoscopic) methods. Routine practice in relation to the inguinal structures varied by volume of hernia surgery; surgeons who conducted more than 50 procedures annually were more likely to visualize and preserve inguinal nerve structures. However, inconsistency in the answers suggested confusion over anatomy. This is the first UK survey to investigate method of hernia repair and usual handling practice of inguinal canal structures. There was wide acceptance of the use of mesh in inguinal hernia repair, with the majority of UK surgeons favoring an open approach. Surgeons performing high volumes of herniorrhaphy were more likely to preserve, rather than transect, inguinal nerve structures. This variation in practice may confound assessment of long-term neuralgia and other post-herniorrhaphy pain syndromes.

Preoperative progressive pneumoperitoneum in patients with abdominal-wall hernias

Induction of preoperative progressive pneumoperitoneum is an elective procedure in patients with hernias with loss of domain. A prospective study was carried out from June 2003 to May 2005 at the Hospital de Especialidades, Instituto Mexicano del Seguro Social, Leon, Mexico. Preoperative progressive pneumoperitoneum was induced using a double-lumen intraabdominal catheter inserted through a Veress needle and daily insufflation of ambient air. Variables analyzed were age, sex, body mass index, type, location and size of defective hernia, number of previous repairs, number of days pneumoperitoneum was maintained, type of hernioplasty, and incidence of complications. Of 12 patients, 2 were excluded because it was technically impossible to induce pneumoperitoneum. Of the remaining 10 patients, 60% were female and 40% were male. The patients' average age was 51.5 years, average body mass index was 34.7, and evolution time of their hernias ranged from 8 months to 23 years. Nine patients had ventral hernias and one had an inguinal hernia. Pneumoperitoneum was maintained for an average of 9.3 days and there were no serious complications relating to the puncture or the maintenance of the pneumoperitoneum. One patient who previously had undergone a mastectomy experienced minor complications. We were able to perform hernioplasty on all patients, eight with the Rives technique, one with supra-aponeurotic mesh, and one using the Lichtenstein method for inguinal hernia repair. One patient's wound became infected postoperatively. Preoperative progressive pneumoperitoneum is a safe procedure that is easy to perform and that facilitates surgical hernia repair in patients with hernia with loss of domain. Complications are infrequent, patient tolerability is adequate, and the proposed modification to the puncture technique makes the procedure even safer.

Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation

To determine whether laparoscopic methods are more effective and cost-effective than open mesh methods of inguinal hernia repair, and then whether laparoscopic transabdominal preperitoneal (TAPP) repair is more effective and cost-effective than laparoscopic totally extraperitoneal (TEP). Electronic databases. Conference proceedings. Manufacturers' submissions to the National Institute for Clinical Excellence (NICE) were reviewed. Selected studies were rigorously assessed. Dichotomous outcome data were combined using the relative risk method and continuous outcomes were combined using the Mantel-Haenszel weighted mean difference method. Time to return to usual activities was described using hazard ratios derived from individual patient data reanalysis. A review of economic evaluations undertaken by NICE in 2001 was updated and an economic evaluation was performed. The estimation of cost-effectiveness focused on the comparison of laparoscopic repair with open flat mesh. A Markov model incorporating the data from the systematic review was used to estimate cost-effectiveness for a time horizon up to 25 years. Thirty-seven randomised control trials (RCTs) and quasi-RCTs met the inclusion criteria on effectiveness. Fourteen studies were included in the review of economic evaluations. Laparoscopic repair was associated with a faster return to usual activities and less persisting pain and numbness. There also appeared to be fewer cases of wound/superficial infection and haematoma. However, operation times are longer and there appears to be a higher rate of serious complications in respect of visceral (especially bladder) injuries. Mesh infection is very uncommon with similar rates noted between the surgical approaches. There is no apparent difference in the rate of hernia recurrence. Laparoscopic repair was more costly to the health service than open repair, with an estimated extra cost from studies conducted in the UK of about 300-350 pounds per patient. The point estimates of cost provided by the economic model also suggest that the laparoscopic techniques are more costly (approximately 100-200 pounds more per patient after 5 years). From the review of economic evaluations, the estimates of incremental cost per additional day at usual activities were between 86 pounds and 130 pounds. Where productivity costs were included, they eliminated the cost differential between laparoscopic and open repair. Additional analysis incorporating new trial evidence suggested that TEP was associated with significantly more recurrences than open mesh but these data did not greatly influence cost-effectiveness. For the management of unilateral hernias, the base-case analysis and most of the sensitivity analysis suggest that open flat mesh is the least costly option but provides less quality adjusted life years (QALYs) than TEP or TAPP. TEP is likely to dominate TAPP (on average TEP is estimated to be less costly and more effective). It is likely that, for management of symptomatic bilateral hernias, laparoscopic repair would be more cost-effective as differences in operation time (a key cost driver) may be reduced and differences in convalescence time are more marked (hence QALYs will increase) for laparoscopic compared with open mesh repair. When possible repair of contralateral occult hernias is taken into account, TEP repair is most likely to be considered cost-effective at threshold values for the cost per additional QALY above 20,000 pounds. The increased adoption of laparoscopic techniques may allow patients to return to usual activities faster. This may, for some people, reduce any loss of income. For the NHS, increased use of laparoscopic repair would lead to an increased requirement for training and the risk of serious complications may be higher. Chronic pain should now be addressed prospectively using standard definitions and allowing assessment of the degree of pain. More evidence is required on the loss of utility caused by persisting pain and numbness, as well as serious complications resulting from minor surgery. Prospective population-based registries of new surgical procedures may be the best way to address this, as a complement to randomised trials assessing effectiveness. Further research relating to whether the balance of advantages and disadvantages changes when hernias are recurrent or bilateral is also required as current data are limited. Methodologically sound RCTs are needed to consider the relative merits and risks of TAPP and TEP. Further methodological research is required into the complexity of laparoscopic groin hernia repair and the improvement of performance that accompanies experience.

Best anesthetic method for inguinal hernia repair?

Best anesthetic method for inguinal hernia repair?

Preferred Mesh-Based Inguinal Hernia Repair in a Teaching Setting

Surgeons' preferences for any of 3 methods of inguinal hernia repair are comparable in terms of operating time, incision length, perceived difficulty, and surgeon's satisfaction. Randomized patient-blinded study. Teaching hospital. A total of 334 patients randomized to receive 1 of the 3 repairs. Patients underwent hernia repair with the Prolene Hernia System, mesh plug repair, or Lichtenstein technique. Operating variables, surgeon's rating of satisfaction and difficulty, grade and experience of the operating team, and complications. The Lichtenstein technique took significantly the longest operating time (52 minutes vs 41 or 42 minutes; P<.001). The mesh plug repair scored the best results in difficulty and satisfaction. Overall, surgeons having performed more than 5 procedures rated the repairs less difficult and with significantly more satisfaction (P<.001 and P = .001, respectively). The complication rate did not differ between the treatment groups. None of the operative findings was correlated to the outcome, except for adverse correlation with the body mass index. From a surgeon's point of view, the mesh plug repair is superior to the Lichtenstein technique and the Prolene Hernia System in terms of operating time, incision length, perceived difficulty, and surgeon's satisfaction.

Laparoscopic techniques versus open techniques for inguinal hernia repair.

Inguinal hernia repair is the most frequently performed operation in general surgery. The standard method for inguinal hernia repair had changed little over a hundred years until the introduction of synthetic mesh. This mesh can be placed by either using an open approach or by using a minimal access laparoscopic technique. Although many studies have explored the relative merits and potential risks of laparoscopic surgery for the repair of inguinal hernia, most individual trials have been too small to show clear benefits of one type of surgical repair over another. The objective of this review was to compare minimal access laparoscopic mesh techniques with open techniques. Comparisons of open mesh techniques versus open non-mesh techniques have been considered in a separate Cochrane review. We searched MEDLINE, EMBASE, and The Cochrane Central Controlled Trials Registry for relevant randomised controlled trials. The reference list of identified trials, journal supplements, relevant book chapters and conference proceedings were searched for further relevant trials. Through the EU Hernia Trialists Collaboration (EUHTC) communication took place with authors of identified randomised controlled trials to ask for information on any other recent and ongoing trials known to them. Specialists involved in research on the repair of inguinal hernia were contacted to ask for information about any further completed and ongoing trials. The world wide web was also searched. All published and unpublished randomised controlled trials and quasi-randomised controlled trials comparing laparoscopic groin hernia repair with open groin hernia repair were eligible for inclusion. Trials were included irrespective of the language in which they were reported. Individual patient data were obtained, where possible, from the responsible trialist for all eligible studies. All reanalyses were cross-checked by the reviewers and verified by the trialists before inclusion. Where IPD were unavailable additional aggregate data were sought from trialists and published aggregate data checked and verified by the trialists. IPD were available for 25 trials, additional aggregated data for seven and published data only for nine. Where possible, time to event analysis for hernia recurrence and return to usual activities were performed on an intention to treat principle. The main analyses were based on all trials. Sensitivity analyses based on the data source and trial quality were also performed. Pre-defined subgroup analyses based on recurrent hernias, bilateral hernias and femoral hernias were also carried out. 41 published reports of eligible trials were included involving 7161 participants. Sample sizes ranged from 38 to 994, with follow-up from 6 weeks to 36 months. Duration of operation was longer in the laparoscopic groups (WMD 14.81 minutes, 95% CI 13.98 to 15.64; p<0001). Operative complications were uncommon for both methods but more frequent in the laparoscopic group for visceral (Overall 8/2315 versus 1/2599) and vascular (Overall 7/2498 versus 5/2758) injuries. Length of hospital stay did not differ between groups (WMD -0.04 days, 95% CI -0.08 to 0.00; p=0.05, but return to usual activity was earlier for laparoscopic groups (HR 0.56, 95%CI 0.51 to 0.61; p<0.0001 - equivalent to 7 days). The data available showed less persisting pain (Overall 290/2101 versus 459/2399; Peto OR 0.54, 95% CI 0.46 to 0.64; p<0.0001), and less persisting numbness (Overall 102/1419 versus 217/1624; Peto OR 0.38, 95% CI 0.4286 to 0.49; p<0.0001) in the laparoscopic groups. In total, 86 recurrences were reported amongst 3138 allocated laparoscopic repair and 109 amongst 3504 allocated to open repair (Peto OR 0.81, 95% CI 0.61 to 1.08; p = 0.16). The use of mesh during laparoscopic hernia repair is associated with a reduction in the risk of hernia recurrence, significantly so for the transabdominal preperitoneal repair (TAPP) versus open non-mesh repair (overall 26/1440 versus preperitoneal repair (TAPP) versus open non-mesh repair (overall 26/1440 versus 47/1119; Peto OR 0.45, 95% CI 0.28 to 0.72; p=0.0009). However, no difference was detected when comparing laparoscopic methods with open mesh methods of hernia repair. The use of mesh during laparoscopic hernia repair is associated with a relative reduction in the risk of hernia recurrence of around 30-50%. However, there is no apparent difference in recurrence between laparoscopic and open mesh methods of hernia repair. The data suggests less persisting pain and numbness following laparoscopic repair. Return to usual activities is faster. However, operation times are longer and there appears to be a higher risk of serious complication rate in respect of visceral (especially bladder) and vascular injuries.

Totally extraperitoneal (TEP) approach for inguinal hernia: the favorable learning curve for trainees

Purpose Endoscopic inguinal herniorrhaphy has become an established approach to groin hernia. The use of a totally extraperitoneal (TEP) approach allows a tension-free, preperitoneal approach with potentially less discomfort and morbidity than do classic repairs. Concerns have been raised regarding excessive cost, need for general anesthesia, and an extensive learning curve for surgeon and resident trainee alike. Methods A retrospective analysis of 264 consecutive patients undergoing TEP for inguinal hernia repair from September 1995 to April 2000 was performed. All repairs were performed by surgical trainees under the supervision of a single staff surgeon. Results Mean age of 256 men and 8 women undergoing 386 inguinal hernia repairs was 54 years (range, 15-86). Inguinal hernias were unilateral (n = 142) or bilateral (n = 122); indirect (52%), direct (33%), or pantaloon (15%); 37 defects (10%) were recurrent. Surgical residents (n = 74) participated in all 264 operations and were considered the “junior surgeon” in 211 cases: 19 chief residents did 35 operations, 9 PG-4s performed 27, 8 PG-3s did 17, 10 PG-2s completed 41, and 28 interns did 91 procedures. Mean operative time was 96 minutes (range, 30-261) with no statistical difference among PG-1s, 2s, 3s, 4s, or chief residents learning the procedure. Early postoperative complications included urinary retention (n = 25), seroma (n = 3), ileus (n = 3), and subcutaneous wound infection (n = 1). Fully 24% of patients desired or required overnight admission. All patients (100%) operated on for recurrence (n = 37) or a previous contralateral repair (n = 19) favored the current TEP approach over their prior repair. Hernia recurrence has developed in 8 patients, with 6 (75%) occurring within the first 40 study patients. Mean follow-up was 3.5 years (range, 1.2-5.9 years). Conclusions The totally extraperitoneal approach is a safe and effective method of inguinal hernia repair. Following a learning curve of 40 patients for the staff surgeon, the recurrence rate has been less than 1%, with surgical trainees safely performing TEP repairs under supervision.

New method of inguinal hernia repair: A new solution: Reply

New method of inguinal hernia repair: A new solution: Reply

New method of inguinal hernia repair: A new solution

A new technique to strengthen the posterior wall of the inguinal canal in all types of inguinal hernias is described. This method of repair is done without mesh and has been developed because mesh is not easily available in rural or remote parts of many countries. After excision of the sac, a strip of the external oblique aponeurosis (EOA) is partially separated from its medial leaf, keeping its continuity intact at either end. This undetached strip of EOA is sutured to the inguinal ligament below and the arch of muscle above, behind the cord, to form a new posterior wall. This strip is put under tension by muscular contraction and works as a shield to prevent recurrence so that the external oblique muscle gives additional strength to the weakened internal oblique and transverse abdominis muscles. A total of 400 patients have been operated on from 1983 to 1999 and follow up by physical examination was carried out. (Eighty patients have been followed up for more than 10 years.) The postoperative period was comfortable with a hospital stay of 2-3 days and a return to work within 1-2 weeks. Recurrence was seen in only one case and haematocoele in one case. These results are comparable with operations performed with mesh. This operation is simple to perform, does not require mesh or extensive dissection and has produced excellent results. Therefore it is a good alternative to mesh or other open or laparoscopic repairs.