Open Inguinal Herniorrhaphy Research Articles

Implications of laparoscopy on surgery residency training

Background With the advent of laparoscopy, many traditional junior-level cases now require advanced laparoscopic skill. We sought to ascertain the implications of laparoscopy on residency training through the use of a large national database. Methods American College of Surgeons National Surgical Quality Improvement Program data were gathered for patients undergoing elective open and laparoscopic inguinal herniorrhaphy, appendectomy, and partial colectomy during 2005 and 2006. Cases were stratified by resident level and compared using univariate analysis. Results A total of 14,729 cases were performed during the study period. For inguinal hernia repair, 72% of open repairs were performed by postgraduate year 3 residents or below versus 41% of laparoscopic repairs ( P < .0001). Similarly, 61% of open appendectomies were performed by postgraduate year 3 residents or below compared with 48% of laparoscopic appendectomies ( P < .0001). Forty-six percent of open colectomies were performed by postgraduate year 3 and postgraduate year 4 residents versus 33% of laparoscopic resections ( P < .0001). Conclusions These data show an upward shift in cases traditionally performed by junior-level residents. The implications of this shift are unknown but may lead to decreased surgical experience during the early years of training.

Laparoscopic Repair of a Ureter Damaged During Inguinal Herniorrhaphy

Laparotomy has been used generally to deal with ureteral injury. Recently, a few papers have reported the repair of gynecologic ureteral injuries by laparoscopy, with encouraging results; however, successful repair of a ureter damaged during an open inguinal herniorrhaphy fully performed by laparoscopy has not been reported yet. A 49-year-old obese man (body mass index=35) in the 10 years before surgery began to note a protrusion in the scrotal region. The protrusion evolved asymptomatically for 8 years, and began to cause pain in the lumbar spine to the right and paresthesia of the right leg. An open right inguinal herniorrhaphy was performed. When the exeresis of the fatty tissue around the spermatic cord was being carried out, resection of a 12-cm tubular structure, supposedly the appendix, was performed. Wall defect was closed by a polypropylene mesh. Acute abdominal pain developed immediately in the postoperative period and investigation using laparoscopy was undertaken. After confirmation of ureteral injury, laparoscopic repair was performed, and the ureter was anastomosed without tension over a double-J catheter. A suction drain was left near the anastomosis. Postoperative period was uneventful. The vesical catheter was withdrawn on the eighth postoperative day and the drain on the twelfth postoperative day. The histopathologic report confirmed that the resected structure was the ureter. The patient has remained asymptomatic for 2 years since the surgery.

Clinical analysis of simnltaneons open prostatectomy and inguinal herniorrhalphy through Turner-Warwick incision

Objective To evaluate the effect of simultaneous open prostatectomy and inguinal herniorrhaphy through Turner-Warwick incision.Methods 12 patients with benign prostatic hyperplasis and inguinal hernia,underwent simuhaneouly suprapubic or retropubic prostatectomy and inguinal herniorrhaphy through Turner-Warwick incision.Results In this series,no infection of ineisional wound occurred.All the patients were followed up for 3 months to 3.5 years.and there was no recurrence.Conclusion Simultaneous open prostatectomy and inguinal herniorrhaphy through Turner-Warwick incision is simple and effective.The infection rate of incision or the recurrence rate of hernia Wag not inereased. Key words: Prostatic hyperplasia; Hernia; inguinal; Surgical procedures; operative

Moloney Darn Repair Versus Lichtenstein Mesh Hernioplasty for Open Inguinal Hernia Repair

To compare two tension-free techniques of inguinal hernia repair: the Moloney darn repair (MDR) and Lichtenstein mesh hernioplasty (LMH). The subjects of this study were 651 patients from a total 732 who underwent open inguinal herniorrhaphy at our clinic between January 2000 and January 2006. We evaluated and compared analgesic requirement in the first 24 h, operative time, hospital stay, early postoperative complications, time until return to work, and recurrence, between patients who underwent MDR (group A) and patients who underwent LMH (group B). Group B patients required less analgesia in the first 24 h than group A patients. Conversely, the mean operative time and postoperative hospital stay were shorter in group A. Early postoperative complication rates and the time until return to work did not differ significantly between the two groups. During follow-up, recurrences developed in three patients from group A and four from group B. The cost of MDR was significantly less than that of LMH. Both MDR and LMH resulted in rapid recovery and low recurrence rates; however, the advantage of the MDR lies in the fact that it does not require mesh, so it is much less expensive.

Laparoscopic Totally Extraperitoneal Hernia Repair Versus Open Lichtenstein Hernia Repair: Results and Complications

Whereas open Lichtenstein inguinal herniorrhaphy is generally accepted as a safe, well-understood method with a high success rate, the laparoscopic repair of a inguinal hernia is a fairly recent technique. Although the laparoscopic approach to a hernia repair procedure is associated with less pain and faster recovery than open repair, many surgeons are not familiar with this technique owing to technical demands and a long learning curve. This study compares the results and complications between open tension-free mesh (Lichtenstein) repair and laparoscopic total extraperitoneal (TEP) repair. The study cohort was comprised of 345 consecutive patients who underwent an inguinal herniorraphy procedure. An open hernia repair was performed on one group of patients (n = 233), whereas TEP repair was performed on the other (n = 112), and then the comparison of intra- and postoperative complications and results obtained from both techniques was done. The mean hospital stay was similar in both groups. The average operative time in the TEP group was 58.6 +/- 18.1 minutes, and the average operative time in the open group was 58.2 +/- 17.8 minutes. There was no difference in postoperative complication rates between the two groups, except for urinary retention, which patients who underwent TEP repair were more likely to get. The following major complications were recorded: 2 cases of urinary bladder perforation-1 during TEP repair and the other during Lichtenstein repair, but both with good postoperative outcome-and 1 case of pneumothorax, which occurred during the TEP procedure. Despite the fact that TEP is a demanding procedure, it may be performed efficiently with an acceptable operating time and a low complication rate.

Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair

Chronic groin pain is the most common long-term complication after open inguinal hernia repair. Traditional surgical management of the associated neuralgia consists of injection therapy followed by groin exploration, mesh removal, and nerve transection. The resultant hernia defect may be difficult to repair from an anterior approach. We evaluate the outcomes of a combined laparoscopic and open approach for the treatment of chronic groin pain following open inguinal herniorrhaphy. All patients who underwent groin exploration for chronic neuralgia after a prior open inguinal hernia repair were prospectively analyzed. Patient demographics, type of prior hernia repair, and prior nonoperative therapies were recorded. The operation consisted of a standard three trocar laparoscopic transabdominal preperitoneal hernia repair, followed by groin exploration, mesh removal, and nerve transection. Outcome measures included recurrent groin pain, numbness, hernia recurrence, and complications. Twelve patients (11 male and 1 female) with a mean age of 41 years (range 29-51) underwent combined laparoscopic and open treatment for chronic groin pain. Ten patients complained of unilateral neuralgia, one patient had bilateral complaints, and one patient complained of orchalgia. All patients failed at least two attempted percutaneous nerve blocks. Prior repairs included Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1). There were no intraoperative complications or wound infections. With a minimum of 6 weeks follow up, all patients were significantly improved. One patient complained of intermittent minor discomfort that required no further therapy. Two patients had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. A combined laparoscopic and open approach for postherniorrhaphy groin pain results in good to excellent patient satisfaction with no perioperative morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after prior open hernia repair.

Chronic Pain and Recurrence After Laparoscopic Inguinal Herniorrhaphy

Chronic pain after open inguinal herniorrhaphy is a complication with an incidence of 10-20% and recurrence in 2-5% of the patients. We here present our experience with the laparoscopic technique. Patients who had undergone laparoscopic inguinal herniorrhaphy (TAPP) in our department from 1995 to 2002 received a questionnaire (N = 161). Patients were asked whether they had chronic pain or recurrence; if so, they were seen in the outpatient clinic. A total of 146 patients responded to the questionnaire (91%). Chronic pain was found in 6 patients (4%) and recurrence in 2 patients (1.4%); 134 patients (92%) had previously had inguinal herniorrhaphy with an open procedure (all Lichtenstein) on the same side. Of these, 105 (78%) preferred the laparoscopic procedure. Laparoscopic inguinal herniorrhaphy led to a very low incidence of chronic pain and recurrence compared with previous reports in open surgery. The majority of our patients were operated on for recurrent hernias, after which an even lower incidence of chronic pain and fewer recurrences in laparoscopic primary herniorrhaphies could be expected.

Laparoscopic Femoral Hernia Repair Using Umbilical Ligament as Plug

A novel technique for the laparoscopic repair of femoral hernia is described. An 11-year-old boy who had undergone previous open inguinal herniorrhaphy presented with a persistent bulge in the ipsilateral groin. At laparoscopic exploration, a small femoral hernia was discovered. It was reduced with extrinsic compression and the defect closed laparoscopically using a permanent purse-string suture. The ipsilateral umbilical ligament was dissected off the abdominal wall and secured (plugged) over the internal opening, providing a tension-free repair. The immediate postoperative result was satisfactory and there was minimal postoperative pain. Two-year follow-up confirmed adequate repair, without recurrence. This laparoscopic technique enabled diagnostic precision, contralateral evaluation, and a novel means of patching and buttressing the peritoneal closure with umbilical ligament. The procedure is safe, simple, and provides excellent functional and cosmetic results.

THE EFFECT OF PREVIOUS TRANSPERITONEAL LAPAROSCOPIC INGUINAL HERNIORRHAPHY ON TRANSPERITONEAL LAPAROSCOPIC RADICAL PROSTATECTOMY

Previous laparoscopic herniorrhaphy has been considered a contraindication to laparoscopic radical prostatectomy (LRP). In this study we analyzed the impact of previous laparoscopic or open inguinal hernia repair on the outcome of transperitoneal laparoscopic radical prostatectomy using the Heilbronn technique. In our database of 1,089 patients with LRP we identified 20 who underwent transperitoneal LRP and had a history of transperitoneal laparoscopic inguinal herniorrhaphy using prosthetic mesh (group 1). The outcome in that group was compared to that of 20 matched pair patients of a total of 95 in whom LRP was performed following open inguinal herniorrhaphy (group 2) and 20 matched pair patients of a total of 771 without previous surgery (group 3). Perioperative parameters (operative time, blood donation and complications) and postoperative results (duration and amount of analgesic treatment, catheterization and the continence rate) were analyzed. According to the matched pair algorithm the 3 groups did not differ with respect to age (63.8, 66.2 and 63.0 years, p = 0.226), prostate volume (47.2, 43.3 and 47.7 gm, p = 0.501) or body mass index (26.1, 25.8 and 26.2 kg/m, respectively, p = 0.641). Ten pelvic lymphadenectomies and 8 nerve sparing (4 unilateral and 4 bilateral) procedures were performed per group. Ten and 12 patients in groups 1 and 2 had a history of bilateral herniorrhaphy, while previous unilateral herniorrhaphy was noted in the remaining 10 and 8, respectively. Mean operative time +/- SD (203.3 +/- 3.54, 196.7 +/- 43.7 and 214.7 +/- 37.7 minutes, p = 0.346) and mean catheterization time (8.1 +/- 2.8, 7.7 +/- 2.5 and 7.4 +/- 2.1 days, respectively, p = 0.684) did not differ significantly among the 3 groups. However, the mean amount of narcotic analgesic was significantly higher in group 1 compared with groups 2 and 3 (32.1 +/- 11.9, 21.8 +/- 11.9 and 19.5 +/- 10.1 mg, respectively, p = 0.002). Continence rates were similar in the groups at 88%, 87% and 92%, respectively, 1 year after surgery. Previous laparoscopic inguinal herniorrhaphy using prosthetic mesh does not adversively affect the operative outcomes or functional results of LRP, while the total amount of narcotic analgesics was significantly higher, reflecting increased postoperative morbidity.

Applied anatomy of the genital branch of the genitofemoral nerve in open inguinal herniorrhaphy.

To record the anatomical variations and clinical importance of the genital branch of the genitofemoral nerve in the inguinal canal. Neuropathology study. General hospital, Taiwan. 58 cadavers. 116 dissections findings of the genitofemoral nerve in the inguinal canal. Anatomical variations. All the genital branches passed through the ventral aspect of the internal ring. Almost all these branches entered the ring and continued within the spermatic cord between the fibres of the cremaster and the internal spermatic fascia. In 59% the nerve was related to the inferior fibres and in 38% it was in relation to the lateral or medial fibres. In only 3% did the genital branch run outside the spermatic cord. To avoid damage to the genital branch of the genitofemoral nerve, suturing should be done over the dorsal aspect of the internal ring. The cremaster should be incised longitudinal rather than transversely and the genital branch of the genitofemoral nerve should be identified before repair of the posterior wall.

Sigmoid colon diverticulosis adherent to mesh plug migration after open inguinal hernia repair

Purpose Tension-free hernia repair with polypropylene mesh plug and patch is currently the most popular technique for open inguinal hernioplasty. It is well tolerated by most patients with few complications. Despite these excellent results, late-onset complications may occur. Methods An 83-year-old man reported 2 weeks of bloody stool. His medical history was significant for a left open inguinal herniorrhaphy with the mesh plug and patch technique. Barium enema revealed a stenotic segment in the sigmoid colon and multiple diverticulosis. Because a malignant lesion could not be ruled out, the patient underwent an operation. Laparotomy revealed an inflamed sigmoid colon with diverticulosis adherent to a hard tumor, which was mesh plug used for the previous open inguinal hernia repair. After mobilization of the adhesion between the mesh plug tumor and the sigmoid colon, sigmoidectomy was performed. The patient’s postoperative course was uneventful. Conclusions We reported a case of sigmoid colon diverticulosis adherent to mesh plug migration after open inguinal hernia repair. The potential risk of plug migration should be well understood by the surgeon. To avoid this risk completely, several methods have been proposed such as suturing the plug and patch together, or using an all-in-one design such as the Prolene Hernia System (Johnson and Johnson Co., Tokyo, Japan).

Short convalescence after inguinal herniorrhaphy with standardised recommendations: duration and reasons for delayed return to work.

To provide a detailed description of post-herniorrhaphy convalescence. Prospective, descriptive, consecutive questionnaire case series. Public university hospital, Denmark. 100 consecutive patients treated for inguinal hernia. Elective open inguinal herniorrhaphy under local anaesthesia. One day convalescence for light/moderate and three weeks for strenuous physical activity was recommended. Duration of absence from work or main recreational activity. Overall median absence (including the day of operation) was 6 days (interquartile range 1-16). For unemployed patients it was 1 day (0-7), for patients with a light or moderate workload 6 days (3-12), and for those with a heavy workload 25 days (21-37). Among the 64 patients, who did not follow the recommendations, pain was contributory in 33 and advice from the general practitioner in 12. Pain was the main cause of impairment of activities of daily living. Well-defined recommendations for convalescence may, together with improved management of postoperative pain, shorten convalescence; they are essential in the evaluation of effects of different surgical techniques of herniorrhaphy on convalescence.

Laparoscopic or Open Inguinal Herniorrhaphy?

We had the opportunity to read the article Laparoscopic or Open Inguinal Herniorrhaphy? A Randomized Prospective Trial by Payne and his colleagues 1 in the September 1994 issue of theArchives. In their article, the authors indicated that in their control group (group 1) a tension-free technique similar to that described by Lichtenstein et al and Amid et al 2 was used. The comparative study is flawed for several important reasons. First, the open tension-free procedure that was described by Payne during his talk at a hernia symposium in Indianapolis, Ind, in June 1993 was the original Lichtenstein procedure prior to its modifications many years ago. The modifications were based on our clinical observations and served to reduce the postoperative pain and recurrence rate. The changes, however, were not published until March 1993, 2 7 months after Payne et al began their study. Therefore, the procedure used in the comparative

Extraperitoneal endoscopic inguinal herniorrhaphy performed without carbon dioxide insufflation.

Laparoscopic extraperitoneal herniorrhaphy is an alternative to the standard open inguinal herniorrhaphy. The procedure is usually done with general or epidural anesthesia and carbon dioxide (CO2) insufflation. Previously, if the peritoneum was perforated in a patient on whom epidural anesthesia was used, conversion to general anesthesia was required because of the resulting pneumoperitoneum. Eliminating CO2 insufflation from the procedure would obviate this problem. The following is a description of the first 5 reported cases of extraperitoneal endoscopic herniorrhaphy done without the need for CO2 insufflation.

Laparoscopic repair of inguinal hernia.

To present the outcome of 123 groin hernias treated laparoscopically between July 1991 and October 1993, and to discuss the advantages of preperitoneal hernia repair with mesh. Data for each patient were collected prospectively on a predetermined standard form. Every patient was assessed by an independent, non-treating surgeon. Ninety-seven patients underwent laparoscopic hernia repair by two surgeons between July 1991 and October 1993. The patients were treated in several private hospitals and one public hospital in Sydney, NSW. Each patient was assessed for integrity of the hernia repair, the number of days before return to work, analgesic requirement after surgery, and complications. There were five hernia recurrences, and repairs in three other patients were considered doubtful by the non-treating surgeon assessor; these repairs were later judged to be sound. There were no infections and no serious complications. There was one scrotal haematoma, one incisional hernia through a trocar site, one hydrocoele and one trocar injury to a large branch of the inferior epigastric artery. Sixty-two per cent of patients required no analgesic injections. Patients covered by workers' compensation returned to work an average of 24 days after their operations and employed patients not covered returned to work an average of 12 days after their operations. Twenty-one patients had been treated previously by open inguinal herniorrhaphy and all enthusiastically endorsed the laparoscopic repair because of reduced pain and earlier return to physical activity. One patient was found to have omental adhesions to the site of the hernia repair at a subsequent laparoscopy. Laparoscopic inguinal herniorrhaphy has the advantages of reduced pain and rapid return to normal activity when compared with open techniques. The mesh prosthesis placed in the preperitoneal space behind the weakened inguinal region appears to confer strength and eliminates the disadvantage of tension observed with sutured repairs.

Inguinal Herniorrhaphy: Complications and Recurrences.

Because laparoscopic surgical techniques have been applied to inguinal hernia repair, the surgeon has been forced to re-evaluate his particular open technique and its resultant complications and recurrences to determine what is the best procedure for patients. In this article, complication rates for open inguinal herniorrhaphy varied from 7% to 12% with some reports as low as 1% using the anterior mesh technique. The most frequent complications were wound problems and scrotal and testicular swelling. In the laparoscopic series using retroperitoneal mesh or the "onlay" technique, the number of complications in 3,288 inguinal herniorrhaphies was 522 (16.8%). On the other hand, recurrence rates for open inguinal herniorrhaphy ranged from 1% to 10% for primary repair to as high as 35% for the repair of recurrent hernias. The laparoscopic series involved 3,178 repairs using the retroperitoneal and onlay techniques, and 61 recurrences (1.92%) were noted in a follow-up greater than 6 months. These data emphasize that complication and recurrence rates are similar between open and laparoscopic inguinal herniorrhaphy.

Inguinal Herniorrhaphy: Complications and Recurrences

Because laparoscopic surgical techniques have been applied to inguinal hernia repair, the surgeon has been forced to re-evaluate his particular open technique and its resultant complications and recurrences to determine what is the best procedure for patients. In this article, complication rates for open inguinal herniorrhaphy varied from 7% to 12% with some reports as low as 1% using the anterior mesh technique. The most frequent complications were wound problems and scrotal and testicular swelling. In the laparoscopic series using retroperitoneal mesh or the "onlay" technique, the number of complications in 3,288 inguinal herniorrhaphies was 522 (16.8%). On the other hand, recurrence rates for open inguinal herniorrhaphy ranged from 1% to 10% for primary repair to as high as 35% for the repair of recurrent hernias. The laparoscopic series involved 3,178 repairs using the retroperitoneal and onlay techniques, and 61 recurrences (1.92%) were noted in a follow-up greater than 6 months. These data emphasize that complication and recurrence rates are similar between open and laparoscopic inguinal herniorrhaphy.

A Prospective Comparison of Laparoscopic and Tension-Free Open Herniorrhaphy

To compare results and outcomes following laparoscopic and tension-free open inguinal herniorrhaphy. A prospective, nonrandomized trial of a single surgeon's experience. A large university hospital. The study included 100 patients with 116 hernias. Patients were offered open hernia repair or, if medically suitable for general anesthesia, a laparoscopic hernia repair. Fifty-seven patients underwent open repair and 43 patients underwent laparoscopic repair. Laparoscopic repair was performed using a transabdominal preperitoneal mesh technique. Open hernia repair was performed using a mesh-plug technique in which the hernia sac was reduced and held in place by a cone of mesh. The floor was covered with a second piece of mesh that encircled the cord and was sutured at the internal ring; it was held in place under the external oblique without sutures. Patients undergoing open repair were older than those undergoing laparoscopic repair. The distribution of hernia types was similar. The laparoscopic operation took longer than the open operation (mean [+/- SD], 1.9 +/- 0.4 hours vs 1.6 +/- 0.4 hours; P < .05), was more expensive ($4165 +/- $1154 vs $2985 +/- $1682; P < .05), and required more postoperative admissions (28% vs 3.5%). There were three recurrences in the laparoscopic group and none in the open group. Patients undergoing laparoscopic repair consumed the same amount of narcotic analgesics as did the group undergoing open repair and had discomfort for the same amount of time. Patients undergoing laparoscopic repair returned to work sooner than did patients undergoing open repair (5.6 days vs 10.3 days; P < .05). Laparoscopic hernia repair returns patients to the workplace faster than open hernia repair despite a similar analgesic requirement. The laparoscopic repair costs more and has a higher recurrence rate than open repair. Laparoscopic repair is most suitable for bilateral hernias. Further investigation of this technique is required before its wide-scale application can be recommended.

Simultaneous open prostatectomy and inguinal herniorrhaphy.

We report our results in 18 patients who had simultaneous open prostatectomy and inguinal herniorrhaphy between 1969 and 1976, and present our criteria for patient selection, operative technic, and postoperative results. The incidence of postoperative wound infection and recurrent hernia was 5.6% and 0 respectively, which compares favorably to results of herniorrhaphy and prostatectomy performed separately. The historic development of this procedure and the results of previously reported series are reviewed.