Total Extraperitoneal Hernioplasty Research Articles

Initial experiences and troubleshooting of Senhance robotic system: A community hospital perspective

Purpose: The purpose of this study is to demonstrate the feasibility and safety of the Senhance robotic system in urologic surgeries. Materials and methods: Patients were included prospectively from July 2018 to December 2020. The exclusion criteria included severe cardiopulmonary diseases and previous extensive abdominal surgeries. Institutional approval and informed consent were obtained. We used the Clavien-Dindo classification system to evaluate the complications that occurred within 30 days after surgery. Common technical and mechanical events encountered were also recorded. Results: A total of 173 patients were recruited. The median age was 65 (58–74) years, and the median body mass index was 24.7 (16.5–35.6) kg/m2. Seventeen (9.8%) patients had previously undergone abdominal surgeries. Eighty-three (48%) cases had total extraperitoneal hernioplasty and 32 (18.5%) cases radical prostatectomy, which were the largest 2 surgeries in our study. Sixty-one (35.3%) patients received surgeries due to malignancy. The median docking time was 5 (1–35) minutes. There were 28 (16.2%) cases with grade I complications and 9 (5.2%) cases with grade II complications. Only one case of a grade IIIb complication occurred during radical prostatectomy. No grade IV complications or mortalities were noted. Robotic arm collisions and forces exceeding the limit were the most commonly encountered problems intraoperatively. Conclusion: In our initial experiences, the Senhance robotic system was feasible in oncologic and nononcologic urologic surgeries and had acceptable outcomes. The haptic feedback system is unique and requires a learning period. This system may serve as an alternative tool for robotic urologic surgeries.

Influence of different peritoneal incision closure methods on the operative outcomes and prognosis of patients undergoing laparoscopic inguinal hernia repair.

The aim was to investigate the effect of different peritoneal tear closure methods on the operative outcomes and prognosis of patients undergo-ing laparoscopic inguinal hernia repair (LIHR). Ninety patients who underwent LIHR in our hospital from August 2019 to December 2020 and had peritoneal tears during the operation were selected, and the patients were divided into a control group (CG) and the observation group (OG) according to different treatment plans, with 45 cases in each group. Patients in the CG were treated with absorbable sutures to repair the peritoneal tears, while patients in the OG were treated with bipolar coagulation to close and repair the peritoneal tears. The surgical conditions, postoperative pain scores, quality of life scores, com-plications, and recurrence were compared between the CG and OG groups. The operation time and hospital stay in the OG were shorter than those in the OG (p<0.05). The pain scores in the OG at 24 hours after operation were lower than those in the CG (p<0.05), and the pain scores of the two groups were not significantly different at two hours and 12 hours (p>0.05). Postoperative complications were not significantly different between the groups (p>0.05). The scores of material life, physical, social, and psychological function in the OG were higher than in the CG (p<0.05). There were no recurrences in the two groups during the 1-year follow-up. Closing repair of peritoneal rupture with bipolar coagulation reduces the operation time of patients with peritoneal rup-ture during TEP (total extraperitoneal hernioplasty) operations, reduces pain, and improves their quality of life. The treatment outcome is safe, effective, and has an excellent clinical application effect.

Effect of spraying bupivacaine and dexamethasone on postoperative pain of total extraperitoneal hernioplasty: a retrospective analysis

Background: Several studies on the reduction of pain with the use of local anesthetics after laparoscopic hernia surgeries have been published. We aimed to analyze the results of local anesthesia applied to the patients by retrospectively scanning the files of patients who underwent total extraperitoneal laparoscopic hernioplasty for inguinal hernias. Methods: The files of patients who underwent TEP laparoscopic hernioplasty for inguinal hernias between March 2019 and November 2022 in Ankara Bilkent city hospital general surgery clinic were retrospectively scanned. The pain scoring records in the observation forms of these patients and the analgesics administered were recorded. Results: A total of 374 and 210 patients underwent unilateral and bilateral TEP laparoscopic hernioplasty, respectively. All of the patients, 232 were not administered any local anesthesia, 186 were administered bupivacaine, and 166 were administered bupivacaine+dexamethasone. When the VAS scores of the patients in both main groups were compared, significant differences were found in VAS scores between patients who received bupivacaine and bupivacaine+dexamethasone and those who did not (p<0.036 and p<0.025). No difference was found between patients who received only bupivacaine and those who were given bupivacaine+dexamethasone. Conclusion: In patients who underwent TEP laparoscopic hernioplasty, spraying bupivacaine into the preperitoneal area after surgery was found to be significantly effective in reducing postoperative pain. The benefits of adding dexamethasone to bupivacaine have not been established.

Therapeutic efficacy of programmed spatial anatomy of the myopectineal orifice in total extraperitoneal hernioplasty: a retrospective study

This study aimed to investigate the therapeutic efficacy of programmed spatial anatomy of myopectineal orifice technique in laparoscopic total extraperitoneal hernioplasty (TEP) surgery. A total of 121 adult male patients with unilateral inguinal hernias who underwent TEP in the Department of General Surgery, Wujin Hospital, affiliated with Jiangsu University, from January 2019 to December 2020 were selected. Patients were divided into the procedural (63 cases) and traditional groups (58 cases) according to the surgical methods adopted. The procedural group underwent programmed spatial anatomy of the myopectineal orifice combined with TEP, and the traditional group underwent traditional TEP. The perioperative evaluation indicators and postoperative complications were observed and compared between the two groups. Compared with the traditional group, the time of handling hernia, the intraoperative operation time, intraoperative blood loss, postoperative ambulation time, and postoperative hospital stay in the procedural group were significantly reduced (P < 0.05). The incidence of postoperative complications such as sensory nerve abnormalities and chronic pain was significantly decreased (P < 0.05), and the total incidence of complications in the procedural group was significantly lower than that in the traditional group (P < 0.05). While there was no significant difference in postoperative incision infection (P > 0.05). The programmed spatial anatomy of the myopectineal orifice can significantly improve the treatment outcome of TEP, significantly improve the patients' intraoperative and postoperative indicators, and reduce the incidence of postoperative complications. It is worthy of being promoted among young physicians and basic hospitals.

РЕЗУЛЬТАТЫ ЛЕЧЕНИЯ ПАЦИЕНТОВ С ПАХОВЫМИ ГРЫЖАМИ В ЗАВИСИМОСТИ ОТ МЕТОДА ГЕРНИОПЛАСТИКИ

The article presents an analysis of the surgical treatment of 224 male patients who underwent inguinal hernioplasty: 90 patients with the Liechtenstein operation, 124 with TEP (total extraperitoneal hernioplasty). The presence of concomitant pathology in patients, the duration of surgery, the need for analgesics, early and late postoperative complications were analyzed. Patients with TEP needed less analgesia in the early postoperative period, they had fewer postoperative wound complications, and their ability to work was restored faster. The Liechtenstein operation was performed in older patients with comorbidities. In the late postoperative period, no recurrence of the disease was observed, regardless of the hernioplasty technique.

Treatment of a Cyst of the Canal of Nuck with an Inguinal Hernia by Laparoscopic Surgery.

A cyst of the canal of Nuck is a rare cystic structure along the inguinal canal extending to the labium majus, which forms due to non-obliterated processus vaginalis. In female patients presenting with painless swelling in the groin or labium, in addition to strangulated hernia, a cyst of the canal of Nuck should be considered. This paper presents a case of a 38-year woman with a right-sided cyst of the canal of Nuck and right inguinal hernia and its clinical and diagnostic features, differential diagnosis, and treatment. Laparoscopic diagnosis and total extraperitoneal hernioplasty (TEP) offer a useful alternative in patients with a superimposed inguinal hernia on top of the cyst of the canal of Nuck. Key Words: Cyst, Laparoscopic surgery, Inguinal hernia, Canal of Nuck.

LAPAROSCOPIC APPROACH IN THE TREATMENT OF INGUINAL HERNIAS IN PATIENTS AFTER RADICAL PROSTATECTOMY: COMPARISON OF TARR AND TER RESULTS

Aim: To compare and evaluate the immediate and long-term results of performing transabdominal preperitoneal hernioplasty (TAPP) and total extraperitoneal hernioplasty (TEP) for the treatment of inguinal hernias after surgical treatment of prostate cancer;Material and method: the study is a clinical analytical prospective study, with the use of randomization. The study included 88 patients with inguinal hernia, who were randomly divided into two groups (group A (n = 44) and group B (n = 44)). Patients in group A received TEP, those in group B received TAPP. The end points of the study were the results associated with the operation itself and the prognosis of the disease in the two groups.Results: Group A: one patient had a scrotal hematoma, in 2 cases nosocomial pneumonia or infectious complications from the postoperative wound. The overall rate of early postoperative complications was 6.8%. In group B, the following postoperative complications were reported: in one case, intestinal injury, 1 case of acute urinary retention, 2 cases of scrotal hematoma. The overall incidence of early postoperative complications was 9.1%. There was no statistically significant difference in the incidence of postoperative complications between the two groups (χ = 0.009, P &gt; 0.05).Conclusion: During the analysis of the obtained results, no statistically significant difference was found in the duration of hospitalization, the volume of blood loss and the severity of the pain syndrome (P&gt; 0.05); however, the comparison groups differed in the duration of the operation: the operation time in group A was longer than in group B. (P＜0.05).

Adding Laparoscopic Iliopubic Tract Repair to Transabdominal Preperitoneal Hernioplasty for Treatment of Recurrent Inguinal Hernia After Totally Extraperitoneal Hernioplasty.

Background: In patients with recurrent inguinal hernia (IH) after totally extraperitoneal (TEP) hernioplasty, re-TEP hernioplasty is difficult because of fibrotic adhesions. Re-laparoscopic hernioplasty is possible by changing the approach from extraperitoneal to transabdominal. If iliopubic tract repair (IPTR), mainly used in the past for the open approach, is added as a laparoscopic procedure, re-laparoscopic hernioplasty is possible when treating recurrent IH. We aimed to evaluate the safety and feasibility of alternate transabdominal preperitoneal (TAPP) hernioplasty supplemented by IPTR for treating recurrent IH after TEP hernioplasty. Methods: We retrospectively evaluated 2600 patients with IHs who underwent TAPP hernioplasty from January 2015 to December 2020. Among patients with recurrent IH, those who underwent primary TEP were included in the study. For reoperation, TAPP hernioplasty was performed and IPTR was added. IPTR was performed by suture closure of the internal inguinal ring by the iliopubic tract and medial aponeurotic arch of the transversus abdominis muscle. Results: Of the 35 patients (33 males and 2 females) with recurrent IH after primary TEP hernioplasty, 51% (18/35) of patients had recurrence within 2 years of the first operation. There were 28 recurrent IHs of the same type as the original, and 7 cases of a different type. The mean TAPP operation time was 41 minutes. Chronic inguinodynia and re-recurrence was not observed. One patient had inferior epigastric vessel injury, which was successfully repaired. Conclusion: Adding laparoscopic IPTR to TAPP hernioplasty is safe feasible treatment for recurrent IH after TEP hernioplasty.

Laparoscopic Totally Extra-peritoneal Hernioplasty versus Lichtenstein Open Tension Free Mesh Repair for Inguinal Hernia

Background: Surgery for a groin hernia is the most common operation in general surgery. The recurrence rate in non-specialized centres is high, and postoperative pain and discomfort are common. The inguinal hernia repair has been a controversial area in surgical practice ever since it was associated with recurrence rates which have decreased because of the use of prosthetic mesh. Objective: This study was aimed to evaluate the benefits and harms of the total extra-peritoneal technique compared with the Lichtenstein technique for inguinal hernia repair. Patients and Material: This randomized controlled trial study included a total of 40 male patients aged between 14 and 60 years with unilateral or bilateral inguinal hernia, attending at Outpatient Clinic, Aswan University Hospital and followed up there. This study was conducted period from August 2017 to August 2018. They were randomly divided into two groups; Group A Open Lichtenstein hernioplasty and Group B; laparoscopic total extraperitoneal hernioplasty (TEP). Results: There was a statistically significant difference between Groups A and B cases as regard operative time and hospital stay. There was no statistically significant difference between Group A and B cases as regard intra-operative/postoperative complications. Also, there was no s statistically significant difference as regard VAS, recurrence in either group during the follow- up period of 6 months. Conclusions: It could be concluded that laparoscopic total extraperitoneal hernioplasty yielded better results regarding operative time and hospital stay. Yet, better results were found regarding complications, but the study could not detect statistical differences.

Does the use of monopolar energy as the preferred mode of dissection effectively reduce seroma formation in laparoscopic total extra peritoneal hernioplasty? A prospective double-blinded randomized control trial.

Seroma is a commonly encountered sequela after hernia repair. Tremendous effort has been spent to investigate the effective way to prevent this "complication" including the modification of surgical technique, use of per-peritoneal drainage, etc. There were debates about the use of monopolar diathermy versus blunt dissection in laparoscopic TEP in the prevention of seroma formation. This randomized study aims to compare the effects of using 2 techniques in laparoscopic TEP on pre-peritoneal drain output and seroma formation. From 1.9.2018 to 30.9.2019, all male and female patients presented with the first occurrence, unilateral inguinal hernia anticipated for laparoscopic TEP were enrolled into the study after informed consent. Patients were randomized into "monopolar dissection preferred" (MDP) group and "blunt dissection-preferred" (BDP) group just before commencing of operation after general anesthesia. Surgeons were instructed to use monopolar energy as main dissection method for the whole operation if possible (MDP), whereas blunt dissection is the preferred choice in BDP group, but the use of monopolar energy was allowed if needed. Total energy time was measured by a specially designed homemade device attaching to the monopolar pedals as accurate as to millisecond (ms). Pre-peritoneal drains were inserted for drainage and removed 23h after operation. Drainage output, total operating time, energy time, clinical and ultrasonic seroma sizes at day 1, day 6, 1-month post operations, recurrence are compared between 2 groups. A total of 103 patients where included. There was no significant difference in age, gender, co-morbidities, side of hernia, mean defect size, operating time, fixation adjuncts, or postoperative stay. The drain volume in BDP group is 71.13 ± 31.42mL while it in MDP group is 56.36 ± 21.46mL. The MDP group had significantly fewer drain output at 23h post operation (p = 0.007) and lower seroma incidence on days 6 (p = 0.036). Overall incidence of seroma formation was 12% on postoperative day 1, 11% on postoperative day 7. No statistically differences in postoperative pain score or complications were observed at the first week, 1- and 3-months' post operation. There was no correlation with energy time to the drain output. No recurrence was found in subsequent follow-up. Pre-peritoneal drainage is clinically safe in laparoscopic totally extra-peritoneal hernioplasty and can effectively reduce the size and incidence of seroma. The seroma formation can be further reduced by appropriate use of monopolar energy as preferred dissection approach in lap TEP. Due to limitation in measuring the actual energy time, the result should be further validated by randomized multi-centers trial on its potential benefit in hernia repair by a more accurate measuring device on energy used.

Dulucq's technique for laparoscopic totally extraperitoneal hernioplasty.

Background:Inguinal hernia repair has been a controversial area in surgical practice. Its complexity is reflected by the fact that numerous different procedures including both open and laparoscopic techniques are in use today. Laparoscopic totally extraperitoneal (TEP) repair is preferred over transabdominal pre-peritoneal repair as the peritoneum is not breached and also due to fewer intra-abdominal complications. This is the most elegant technique but rather difficult to perform.Aim:The purpose of this study was to describe Dulucq's technique for inguinal hernia repair and the use of three-dimensional mesh without fixation in laparoscopic TEP inguinal hernioplasty.Methods:Surgical technique of laparoscopic TEP inguinal hernia repair is detailed in the text.Results:A total of 945 hernia repairs were included in the study. The hernias were repaired by Dulucq's technique. Mean operative time was 45 min in unilateral hernia and 65 min in bilateral hernia. There were no serious complications.Conclusion:The laparoscopic TEP hernioplasty by Dulucq's technique is feasible with fewer intra-abdominal complications. The dissection must always be done with the same stages with minimal monopolar diathermy and patient in a slight Trendelenburg position.

The choice of surgical treatment of inguinal hernia (literature review)

Inguinal hernioplasty is one of the most common surgical procedures, but the long-term results of operations leave much to be desired: there are recurrences of hernias, chronic pain syndrome, violation of testicular function in men. A modern review of the literature on the most common surgical methods of treatment of inguinal hernias is presented. Separately, describes the methods of hernioplasty with using local tissue (autodermaplasty) and with the use of mesh implants (allohernioplasty). Material allohernioplasty set out on the basis of their surgical approaches are used: traditional (open) and laparoscopic. Special attention is paid to the necessary properties of the mesh implant, the choice of the method of its fixation. The advantages and disadvantages of the most common methods of hernioplasty are listed. Currently, there is no single standard for inguinal hernioplasty. The choice of the method is based on the experience of the surgeon, technical capabilities and desires of the patient. The most commonly used methods for autoplasty are Desarda and Shouldies, and among allogernioplasty - Liechtenstein technique (traditional surgical access) and laparoscopic methods (transabdominal preperitoneal hernioplasty, total extraperitoneal hernioplasty).

Evaluation of Laparoscopic Total Extraperitoneal Repair of Inguinal Hernia Under Regional Anesthesia: A Prospective Case Series

This study evaluated the feasibility and safety of laparoscopic total extraperitoneal (TEP) inguinal hernioplasty under regional (spinal/epidural) anesthesia, on the basis of duration of surgery, conversion to general anesthesia (GA), intra-operative and post-operative complications, post-operative hospital stay, time taken to resume normal activity and recurrence. A prospective observational study was conducted from 1st November 2014 to 31st December 2015 on a series of 33 patients with direct or indirect inguinal hernia treated in the Department of General Surgery. All the patients underwent laparoscopic TEP hernia repair under regional anesthesia and the outcome was evaluated. The study included 33 patients, 32 male and 1 female. All the patients were operated on under regional anesthesia and the operative procedure performed was laparoscopic TEP. There was no conversion of the operative procedure from TEP to the transabdominal preperitoneal (TAPP) procedure or to open hernioplasty, but conversion of regional anesthesia to GA was needed in 5 cases, because of hypotension, shoulder tip pain, pneumoperitoneum, intraoperative straining and/or inadequate preperitoneal space. A sensory level achieved after regional anesthesia below T6 was found to be a significant reason for conversion to GA. The mean post-operative hospital stay was 3.9 ± 0.9 days (range 2–6 days). The mean time taken to resume normal activity was 13.3 ± 1.8 days (range 10–15 days). TEP hernioplasty is a feasible and safe procedure which can be performed under regional anesthesia and on patients who are at high risk or unfit for GA as well as in patients with no other problems.

Evaluation of laparoscopic total extraperitoneal hernioplasty versus open hernioplasty in the management of uncomplicated inguinal hernia

Background: Inguinal hernia repair is one of the most common operations in general surgery. Inguinal hernias are among the most common of abdominal wall hernias accounting for almost 75% with lifetime risk of 27% in men and 3% in women. Laparoscopic techniques for inguinal hernia repair, shown to be superior to open repair in terms of postoperative pain and recovery.Methods: In this study, 54 patients with inguinal swelling were taken, 27 cases each for laparoscopic TEP repair and 27 for open mesh repair were studied and results were analyzed.Results: This study shows the maximum number of patients were in the age group of 51-60years in open repair whereas 41-50years in laparoscopic TEP repair. In both the groups, right sided hernia is common. Time duration of surgery varies from 47minutes to 90minutes in open hernia repair whereas in laparoscopic repair it was 85minutes to 136.67minutes. This longer duration of surgery was attributed to learning curve. The mean duration of hospital stay was 3.26days in laparoscopic TEP repair compared to 5.85days in open repair group.Conclusions: Laparoscopic TEP repair offers a significant advantage over open mesh hernia repair. It is associated with less postoperative pain and complications, early post-operative recovery and reduced hospital stay and early resumption of normal activity and better quality of life. However, operative time was prolonged in laparoscopic TEP repair as compared to open due to the learning curve in the institution.

Comparative study of polyester vs polypropylene mesh in laparoscopic inguinal hernia repair

Background: Despite of convincing advantages offered by meshes, their use in hernia surgery remains controversial due to their long-term effects. A lighter and softer mesh may decrease chronic pain and recurrence by creating less fibrosis in laparoscopic inguinal hernia repair.Methods: This study was conducted with an aim to evaluate the incidence of chronic groin pain and recurrence in polyester mesh and polypropylene mesh groups of patients in laparoscopic total extraperitoneal hernioplasty. 40 patients with simple uncomplicated inguinal hernia subjected to TEP hernioplasty using either Polyester mesh or Polypropylene mesh after being randomized into two groups over a period of one year at Department of General Surgery at SSG Hospital, Baroda. Operative data were recorded, and the patients were followed-up accordingly. Independent assessors were assigned to obtain incidence of chronic groin pain and recurrence and other secondary outcomes.Results: Chronic pain, post-operative pain scores, duration of hospital stay, early return to daily activity, and feeling of lump were significantly lower with polyester mesh as compared to Polypropylene mesh. However, there was no significant difference in both the groups with respect to recurrence and post-operative complications.Conclusions: A polyester mesh has better long-term outcomes for chronic pain, post-operative pain scores, duration of hospital stay, early return to daily activity, and feeling of lump compared with a polypropylene mesh in laparoscopic inguinal hernia repair.

The Relevance of Sexual Dysfunction Related to Groin Pain After Inguinal Hernia Repair - The SexIHQ Short Form Questionnaire Assessment.

BackgroundChronic postoperative pain after inguinal hernia surgery can affect sexual function. A new short form questionnaire for inguinal hernia pain related sexual dysfunction (SexIHQ) was introduced and applied to a register based cohort of total extra-peritoneal hernioplasty (TEP) operated patients.MethodsSexually active men, 30–60 years old, recorded in the Swedish Hernia Register for a primary inguinal hernia TEP operation were included. Two initial questions of the SexIHQ identify patients with pain at sexual activity. Only these patients proceeded to answer the specific questions on pain-induced impairment of sexual activity, pain frequency and intensity, physical functions (erection and ejaculation), and symptoms of depression. SexIHQ, the Short Form-36 (SF-36), the Inguinal Pain Questionnaire (IPQ) were mailed to participants for long term follow up.ResultsIn 538 included patients, 44 (8.2%) reported pain during sexual activity at mean 33 months after surgery. Sexual dysfunction was seen in 33 of these patients. A postoperative complication was a risk factor for pain during sexual activity; OR 4.89 (95% CI 1.92–12.43; p < 0.001). Quality-of-life was reduced in almost all SF-36 domains in patients with pain during sexual activity.ConclusionsA short form questionnaire, suitable for large cohorts, was developed to assess sexual dysfunction due to groin pain after inguinal hernia repair in male patients. Sexual dysfunction due to groin pain after hernia surgery by TEP is surprisingly common. Patients should preoperatively be informed of the risk of having pain during sexual activity following groin hernia surgery.

Preperitoneal closed-system suction drainage after totally extraperitoneal hernioplasty in the prevention of early seroma formation: a prospective double-blind randomised controlled trial.

Seroma is a virtually unavoidable early sequela after TEP hernioplasty. This randomised controlled trial evaluated the outcomes of preperitoneal closed-system suction drainage in laparoscopic totally extraperitoneal (TEP) hernioplasty for inguinal hernia. Ninety patients aged 18-80years who presented to our hospital between May 2016 and February 2017 with primary unilateral inguinal hernia were randomised into the preperitoneal drain and no-drain groups. The primary outcome was seroma size on postoperative day 6. Secondary outcomes included clinical seroma formation and seroma size on day 1, day 6, 1 and 7months postoperatively, length of postoperative stay, pain score, and recurrence. There was no significant difference in age, sex, co-morbidities, hernia side, mean hernia size, operating time, fixation adjuncts, or postoperative stay. The overall incidence of clinical seroma formation was 25.6% on postoperative day 1, 60.3% on postoperative day 6, 13.2% 1month and 0% 7months postoperatively. The mean drain output was 57.9ml. The drain group had significantly fewer patients with seroma on day 1 (6 vs 14, p=0.022) and day 6 (17 vs 30, p=0.000), and a smaller mean seroma size on days 1 and 6 (p=0.000). Subgroup analysis showed that sac ligation versus reduction, peritoneal perforation, and fixation adjuncts had no significant effects on seroma formation or size. There is a trend of lower early post-operation VAS score and more urinary retention in drain group was observed but not reaching statistical significance. No differences in postoperative pain score or complications were observed at 1 and 7months' post operation. Preperitoneal drainage for 23h after laparoscopic TEP hernioplasty for inguinal hernia can effectively decrease seroma formation in the early postoperative period, and potentially improving postoperative pain. The benefit is short-term and no significant difference was demonstrated after 1-month post operations. This tradition technique applied to novel operative repair of inguinal hernia is safe and feasible with no significant morbidity demonstrated. Preperitoneal drainage after TEP can be considered as an option to improve patient satisfactions and recovery in selected patient group for maximal benefit, especially for those with prolonged operation which may associate with higher chance of seroma formation.

Laparoscopic totally extra peritoneal (TEP) inguinal hernia repair: A series of 47 cases

Background: Over the past years, several surgical techniques have been evolved, among which total extraperitoneal inguinal hernia repair is the laparoscopic technique which is more popular now.Objective: To evaluate the outcome of totally extra peritoneal laparoscopic hernioplasty in terms of operation time, hospital stay and complications.Methods: The prospectively designed descriptive study was carried out at Department of Surgery Unit III, Kathmandu Medical College Teaching Hospital from February 2014 to April 2015. Forty seven consecutive patients above 15 years of age underwent totally extra peritoneal repairs for inguinal hernias. The selection criteria were reducible primary or recurrent, unilateral, direct and indirect inguinal hernias. All the relevant details of each patient were noted subsequently and analyzed statistically using Statistical Program for Social Sciences (SPSS) version 15.Results: The mean age of patient was 49±2.5 years. The mean operation time was 65±5.3 minutes. There were no serious complications except four (8.5%) cases of groin seroma which resolved after single time aspiration. Three (6.3%) cases had developed recurrence, two (4.2%) had developed hydrocele in a median follow up period of 6±1.5 (range, 3-9months). The mean inpatient hospital stay was 1.7±0.2 (range, 1-2.4days).Conclusion: Total extra peritoneal hernioplasty is safe and feasible with acceptable complications and recurrence rates.Journal of Kathmandu Medical College, Vol. 5, No. 4, Issue 18, Oct.-Dec., 2016, page: 120-123

Learning curve takes 65 repetitions of totally extraperitoneal laparoscopy on inguinal hernias for reduction of operating time and complications.

Inguinal hernia repair is one of the most frequently conducted surgical procedures worldwide. Totally extraperitoneal (TEP) hernioplasty has shown many advantages over traditional open surgery. However, because of increased surgical complexity, it requires more practice to achieve optimal results. The aim of this study is to evaluate the learning curve for TEP hernioplasty, analysing parameters related to the mean operating time. The secondary objective is to assess the complications and early discharge rates related to this procedure. A prospective study of 238 consecutive patients undergoing TEP hernioplasty from the same practitioner between May 2009 and May 2014, in a specialised centre for abdominal hernias in Sao Paulo, Brazil, was conducted. All data were obtained through medical records. The study included 137 patients undergoing a total of 157 TEP hernia repairs. Bilaterality and complications can influence the operating time and so were excluded. Patients with unilateral surgery and without complications were included. Patients were chronologically divided into four groups. Groups 1-3 were composed of 35 patients and group 4 of 32. There were no significant variations in clinical characteristics between the groups. The plateau of the learning curve was reached on the 65 th repetition of the surgery, with a mean operating time of 28min (p < 0,05). Complications were only observed in the first group of 35 patients. 97% of patients were discharged early, defined as patient leaving hospital less than 12h after surgery. After an initial reduction, the mean operating time stabilised after 65 cases. A reduction in the rate of complications was observed after 35 cases, and a rate of 97% of early discharge was achieved.

Perioperative Platelet Inhibition in Elective Inguinal Hernia Surgery—Increased Rate of Postoperative Bleeding and Hematomas?

In patients on oral antiplatelet therapy secondary to critical vascular diseases, the risk of interrupting antiplatelet therapy has to be weighed against the risk of postoperative hematoma or bleeding when surgery is planned. The goal of this study was to determine the risk of postoperative hematoma and postoperative bleeding in elective inguinal hernia surgery during continuous platelet inhibition. Patients receiving either elective total extraperitoneal hernioplasty or Lichtenstein repair for inguinal hernia were included. Patients with mere suture repair, emergency hernia repair, combination of different simultaneous operations, and patients under therapeutic anticoagulation with heparin were excluded. Postoperative bleeding/hematoma was determined by physical examination and graded according to the Clavien-Dindo classification. Between January 2006 and December 2013, 561 patients with elective surgical repair of an inguinal hernia were included. A total of 29 patients were under continuous perioperative platelet inhibition (PI) with either aspirin or clopidogrel in addition to perioperative antithrombotic prophylaxis with subcutaneous dalteparin injections (PI group). A total of 532 patients received perioperative antithrombotic prophylaxis only (control group). The number of patients under antiplatelet therapy increased from 1.3% (Jan. 2006–Dec. 2009) to 10.0% (Jan. 2010–Dec. 2013; P &amp;lt; 0.0001). Postoperative hematoma/bleeding occurred in 5 PI patients (17.2%) versus 38 control patients (7.1%, P = 0.062). Rate of postoperative bleeding or hematoma is not higher under mono antiplatelet therapy for elective inguinal hernia repair. Since the majority of hematomas can be treated conservatively, it seems unnecessary to stop mono platelet inhibition perioperatively.