Cost-effectiveness of open versus laparoscopic repair for primary inguinal hernia

A cost-effectiveness (CE) analysis was performed of Bassini versus laparoscopic repair for primary inguinal hernia. Incremental costs per 1-year recurrence-free patient were calculated for the societal and hospital perspective. From the hospital perspective, the incremental CE ratio of laparoscopic repair is 5.348 guilders. From the societal perspective, laparoscopic repair is both less costly and more effective than Bassini repair. Results were sensitive to assumptions about recurrence rates, laparoscopic operating time, and return to work. Laparoscopic repair should replace Bassini repair in order to benefit society. From the hospital perspective, the decision to accept laparoscopic repair depends on the willingness to pay.     

The Lichtenstein "tension free" operation for inguinal hernia

The authors present their experience with operations of 264 inguinal hernias in 238 subjects where Lichtenstein's technique was used. The principle of the operation is reconstruction of the posterior wall of the inguinal canal by means of a synthetic mesh-tension free. The attained results in this group (L) were compared with a control group of 68 operated patients (group C) where the classical McVaye technique was used. They did not find a difference in the time taken up by the operation or the time of hospitalization. The postoperative mortality was 0.4% in group L and 2.9% in group C, the morbidity was 15.5% and 42.6% resp. So far they did not record a case of relapsing hernia or rejection of the mesh. The operation is easy to perform, economically unpretentious, the postoperative pain is milder and the sensation of discomfort slighter than after the classical operation. With regard to the assembled experience, the authors recommend the new operation not only in inguinal but also other types of hernias where tension free repair is impossible. For reconstruction they use polyester mesh CHS 100 manufactured by the Hosiery Research Institute in Brno.     

Historical evolution of inguinal hernia repair

In periods of change, psychiatric services must project outcomes of decisions about service innovations and reductions, including budgetary implications. To support such decision making, a public-sector psychiatric service in Melbourne, Victoria, Australia, developed a modeling tool that combines data from its service activity database and budgetary information with modeling techniques based on use of a spreadsheet. The model is based on clients' use of three major service components: the inpatient unit, continuing clinical care and consultancy services, and crisis assessment and treatment services. It classifies clients according to patterns of care-that is, whether they used one, two, or three of the components, in various combinations. The authors report service use and financial data derived from the model for the financial year 1992-1993. They describe two scenarios for using the model to project changes in patterns of care and costs when new services are implemented. Such a model can clarify costs, including opportunity costs, of management decisions and facilitate participation of senior clinicians in active service planning within the realities of budgetary constraints.     

The Lichtenstein open "tension-free" mesh repair of inguinal hernias

All standard methods of hernia repair involve suturing together tissues which are not normally in apposition. This violates the basic surgical principle that tissue must never be approximated under tension and thus accounts for an unacceptable number of failures. A total reinforcement of the inguinal floor with a sheet of suitable biomaterial and the employment of a "tension-free" technique is a more effective approach. Since June of 1984, 4,000 primary inguinal hernias have been repaired on an outpatient basis and under local anesthesia at the Lichtenstein Hernia Institute by the open "tension-free" technique using Marlex mesh. The patients were followed from one to 11 years (mean of 5 years) by physician examination. The follow-up rate was 87%. There were four recurrences. The causes of recurrence and how to avoid them are discussed herein. Three of the recurrences occurred at the public tubercle and were caused by placing the mesh in juxtaposition to the tubercle. This error has since been corrected by overlapping the mesh at the public bone. One recurrence was caused by disruption of the lower edge of the mesh from the shelving margin of Poupart's ligament. The error here was the utilization of a patch that was too narrow and therefore under tension. It became apparent that a wider patch, fixed in place with an appropriate degree of taxity, was required.     

Prospective randomized trial comparing Shouldice and Bassini-Kirschner operation technique in primary inguinal hernia repair

The authors conducted a prospective randomized trial to compare the Shouldice and the Bassini-Kirschner technique between April, 1994 and December, 1995. During this period 129 adult patients, mean age 54 (17-87) years underwent operation on primary inguinal hernias in their department. 63 Shouldice and 66 Bassini-Kirschner operations were performed by 17 surgeons. The duration of surgery, the technique of anesthesia, the perioperative complications, the duration of postoperative care, then one year after the operation the recurrence rate and the patient's subjective complains were investigated. 85 patients of 129 were examined one year after the operation in spite of that all the patients were invited for control. Both operations gave almost the same results in the perioperative period and nearly identical recurrence rate (4.44% in Shouldice and 5.0% in Bassini-Kirschner group). The patient's subjective complains were also very similar one year after the operation. The authors could not find significant difference in the results of the two types of surgery although they were well experienced with the Bassini-Kirschner operation and just starting to practice the Shouldice procedure. These facts suggest that having more experience with the Shouldice operation makes available the extreme low recurrence rate published by several authors.     

Herniography in symptomatic patients following inguinal hernia repair

Patients with symptoms at the site of a previous inguinal hernia repair may constitute a diagnostic dilemma. The usefulness of herniography in the assessment of these patients was evaluated at 54 symptomatic sites in 46 subjects. Ten persistent or recurrent hernias were shown by herniography, only 2 of which were definitely detected on physical examination. The herniogram was normal at 44 sites, of which, on physical examination, 5 were equivocal and 1 was diagnosed as a definite hernia. On the unoperated-on or asymptomatic side, a total of 14 hernias were shown herniographically. Of these hernias, 8 were not detected on physical examination. Herniography was found to be more sensitive than physical examination in detecting hernias at the symptomatic, previously operated-on sites, as well as at the unoperated-on or asymptomatic sites. When a herniogram provides corroborative evidence that hernia has not recurred, the need for reexploration may be eliminated.     

Nerve injury during laparoscopic inguinal hernia repair

This report presents a case of injury to the lateral cutaneous nerve of the thigh during laparoscopic inguinal hernia repair. Both this nerve and the femoral branch of the genitofemoral nerve are at risk during laparoscopic inguinal hernia repair. Pertinent anatomy is reviewed and suggestions made to prevent this injury. This case does not appear to be an isolated event, and hopefully this report will bring attention to this potential complication.     

Overview of randomized trials in laparoscopic inguinal hernia repair

Purified phenolic glycolipid (PGL-1) from Mycobacterium leprae was used to detect IgG antibodies against PGL-1 in leprosy patients in an enzyme-linked immunosorbent assay (ELISA). A total of 698 sera were screened; they came from patients suffering from leprosy, autoimmune disease, myeloma, tuberculosis and sexually transmitted diseases (STDs). Cases with miscellaneous diseases and persons undergoing AIDS screening were also included. Sera from lepromatous and tuberculoid leprosy patients gave positivity rates of 60.5% and 41.7%, respectively. In non-leprosy cases, the PGL-1 ELISA showed an overall positivity rate of 6.9%; this was greatest in patients with tuberculosis (43.8%) followed by autoimmune diseases (40.9%) and miscellaneous cases including liver diseases (37.9%). This study emphasizes that PGL-1 ELISA has a low predictive value for diagnosis of active infection by Mycobacterium leprae. Positive reactions in a significant percentage of patients with autoimmune disease are intriguing and need indepth study.     

New trends: preperitoneal laparoscopic inguinal hernia repair

This paper focuses on the meaning and process of collaboration, particularly in the area of research and clinical practice. Much has been written about the existing gaps between research and the practice of nursing; however, action research is one mechanism that allows these elements to be drawn together. Research developed through collaborative participation has the potential to harness the energy, enthusiasm and talents of nurses at different levels and practice into a cohesive group motivated to achieve professional development and quality practice goals. Action research that is built on the philosophy of a quality within the process and significance of the group can lead to effective practice in nursing. Power can be found in partnership.     

Ambulatory inguinal hernia repair compared with short-stay surgery

Two groups of patients operated on for inguinal hernia, one outpatient group and one inpatient group, are compared with respect to subjective distress and immediate postoperative complications. The groups were chosen at random and matched for sex and age. A large number of those who received treatment as outpatients suffered marked distress during the first postoperative days. Some form of intermediary or light nursing should be tried out for the outpatients so that if necessary they can stay the night after operation at the hospital. The number of postoperative complications was equal in the two groups. With suitable patient selection and with a small number of reserve places in a light-care ward, the majority of inguinal hernia operations can be performed on outpatients, resulting in a considerable economic saving and shorter waiting time.     

Respiratory compliance during laparoscopic hiatal and inguinal hernia repair

BACKGROUND: Arginine vasopressin (AVP) not only acts directly on blood vessels through V1 receptor stimulation but also may modulate adrenergic-mediated responses in animal experiments in vivo and in vitro. The aim of the present study was to investigate whether AVP can contribute to an abnormal adrenergic constrictor response of human saphenous veins. METHODS AND RESULTS: Saphenous vein rings were obtained from 32 patients undergoing coronary artery bypass surgery. The vein rings were suspended in organ bath chambers for isometric recording of tension. AVP (3x10[-9] mol/L) enhanced the contractions elicited by electrical field stimulation at 1, 2, and 4 Hz (by 80%, 70%, and 60%, respectively) and produced a leftward shift of the concentration-response curve to norepinephrine (half-maximal effective concentration decreased from 6.87x10[-7] to 1.04x10[-7] mol/L; P<.05). The V1 vasopressin receptor antagonist d(CH2)5Tyr(Me)AVP (10[-6] mol/L) prevented the potentiation evoked by AVP. The selective V1 receptor agonist [Phe,2 Orn8]-vasotocin (3x[-10]-9 mol/L) induced potentiation of electrical stimulation-evoked responses, which was also inhibited in the presence of the V1 receptor antagonist (10[-6] mol/L). In contrast, the V2 receptor agonist desmopressin (10[-9] to 10[-7] mol/L) did not modify neurogenic responses, and the V2 receptor antagonist [d(CH2)5, D-Ile,2 Ile,4 Arg8]-vasopressin (10[-8] to 10[-6] mol/L) did not prevent the potentiation induced by AVP. The dihydropyridine calcium antagonist nifedipine (10[-6] mol/L) did not affect the potentiating effect of AVP. CONCLUSIONS: The results suggest that low concentrations of AVP facilitate sympathetic neurotransmission and potentiate constrictor effects of norepinephrine in human saphenous veins. These effects appear to be mediated by V1 receptor stimulation and are independent of calcium entry through dihydropyridine calcium channels. Thus, AVP may contribute to vascular mechanisms involved in acute ischemic syndromes associated with venous grafts, particularly if the sympathetic nervous system is activated.     

Endoscopically guided percutaneous repair of inguinal hernia through a 2-cm incision. Minihernia repair

BACKGROUND: The laparoscopic repair of inguinal hernia is still controversial. Transabdominal preperitoneal repair violates the peritoneal cavity and may result in visceral injuries or intestinal obstruction. The laparoscopic extraperitoneal approach has the disadvantage of being technically demanding and requires extensive extraperitoneal mobilization. The Lichtenstein repair gives good long-term results, is easy to learn, can be performed under local anesthesia, but requires a larger incision. METHODS: We describe a novel percutaneous tension-free prosthetic mesh repair performed through a 2-cm groin incision. The inguinal canal is traversed with the aid of a 5-mm video-endoscope and the canal is widened using specially designed balloons. Spermatic cord mobilization, identification and excision of the indirect sac, and posterior wall repair are carried out under endoscopic guidance. RESULTS: Between October 1993 and July 1995, 85 primary inguinal hernia repairs (48 indirect and 33 direct) were performed on 81 patients (80 men, one woman) by the author (A.D.). The mean age was 41 years (range 17-83 years). Six repairs were performed under local anesthetic. Mean operative time was 42 min (range 25-74). Mean hospital stay was 1.2 days (0-3 days). The mean return to normal activity was 8 days (2-10 days). Eight complications have occurred: a serous wound discharge, two scrotal hematomas, a scrotal swelling that resolved spontaneously, wound pain lasting 2 weeks, an episode of urinary retention, and two recurrences early in the series (follow-up 1-22 months). CONCLUSION: The endoscopically guided percutaneous hernia repair avoids the disadvantages of laparoscopy (i.e., lack of stereoscopic vision, reduced tactile feedback, unfamiliar anatomical approach, risk of visceral injury), yet the use of endoscopic instrumentation allows operation through a 2-cm incision. The minihernia repair thus combines the virtues of an open tension-free repair with minimal access trauma.     

Laparoscopic transperitoneal versus extraperitoneal inguinal hernia repair: a prospective clinical trial

Myoporum laetum was collected in the municipalities of Rio Grande and Capao do Leao in winter and in Santa Vitoria in summer, autumn, winter and spring, in the state of Rio Grande do Sul, Brazil, and in the Department of Rocha, Uruguay, in winter and spring. The fresh green plant was fed to 17 sheep. All sheep developed clinical signs, except 1 that consumed only 4 g/kg bw daily during 10 d. Five of the 9 sheep dosed with 40 g/kg died. Four sheep dosed with plants from Uruguay at 40 g/kg, 6 sheep dosed with 20 g/kg, and 1 sheep dosed with 2 daily doses of 8 g/kg survived. Clinical signs were anorexia, restlessness, ruminal stasis, jaundice and dry feces with mucus or blood. All surviving sheep had photodermatitis in the face, ears, eyes and lips. Histologic lesions were characterized by periportal liver necrosis. Serum levels of AST, GGT and bilirubin were increased. M laetum from Uruguay was less toxic, suggesting a variation in toxicity among plants from different regions.     

Acquired umbilical fistula after repair of inguinal hernia: a case report

A 2-year, 9-month-old boy had an umbilical fistula after repair of an inguinal hernia at 8 months of age. Fistulography findings showed a duct running from the umbilicus toward the inguinal wound. Pathological finding of the surgically removed fistula demonstrated granulomatous tissues containing silk ligature. Acquired umbilical fistula is a rare complication of inguinal herniorrhaphy. Its clinical details as well as a review of the previously reported four cases are presented.     

Randomized placebo-controlled trial of local anaesthetic infusion in day-case inguinal hernia repair

Irinotecan has been approved in Japan, France and USA, however, its clinical usefulness seems to be differently understood. There is a strong opinion, especially in Japan, that the drug is too toxic since it may harm as many patients than it helps. On the contrary, irinotecan is well accepted to the US cancer chemotherapy practices. With irinotecan as a typical example of new chemotherapeutic agents, benefit and risk of cancer chemotherapy is discussed. Differences in cancer chemotherapy practices between Japan and USA are discussed as well.     

A new preperitoneal repair for inguinal hernia using a transpositioned external oblique aponeurotic flap

This study consists of a preliminary report of 94 cases with various types of inguinal hernias. All cases were repaired by a new technique, in which the herniotomy is performed via a preperitoneal approach and the repair is achieved by using a bipedicled flap from the external oblique aponeurosis, which is transpositioned into the preperitoneal space and sutured to the iliopubic tract. The details of this technique are herein described. After a follow-up ranging from 15 to 48 months, both the early and late complications are presented. They were minimal and of minor significance, apart from a hernial recurrence in one case.     

Three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia

BACKGROUND: Controversy exists over the relative advantages of open mesh repair compared with open stitching methods and the laparoscopic approach. STUDY DESIGN: Two thousand nine hundred six (2,906) consecutive unselected adult patients underwent 3,175 primary inguinal hernia repairs using polypropylene mesh, under local anesthesia on an ambulatory basis. The age range was 15-92 years. The study specifically investigated the postoperative course with regard to pain, complications, and time of return to work. RESULTS: There were no postoperative deaths and no cases of urinary retention. Two percent of patients developed a hematoma. The incidence of deep infection was 0.3%. No case of testicular atrophy occurred. Postoperatively 19% of patients used no analgesia at all; 60% used oral analgesics for up to 7 days. There was a gradual decrease in time of return to work over four successive 1-year periods. Manual workers returned to work in 15 days (median) in the first year, reducing to 9 days in the fourth year. The overall median time of return to work across the whole group was 9 days. There were eight recurrences with an 18-month to 5-year followup. CONCLUSIONS: Open mesh repair under local anesthesia is an effective day case technique, particularly in the elderly and medically unfit. The economic benefits are enhanced by low morbidity, early return to normal activities and low recurrence rates.