Prospective randomized comparative study of laparoscopic hernioplasty and Lichtenstein tension-free hernioplasty]

To compare the laparoscopic transabdominal preperitoneal inguinal hernioplasty (TAPP) and the open Lichtenstein technique, in 1992 a prospective randomized trial was initiated. Until 1995 108 patients with 130 hernias took part in the trial: 64 TAPP (group A) and 66 Lichtenstein (group B). 22 patients had simultaneous bilateral repairs. Laparoscopic approach (group A) was able to expose otherwise-occult controlateral hernias in 3 cases and discovered a complex hernia (a hernia with more than one defect in the wall) in 2 patient in whom a direct hernia had been diagnosed before the operation. Mean operating time for monolateral operations was significantly longer in group A (p < 0.05). The corresponding figures for bilateral operations were longer in group B (p < 0.01). No intraoperative complications, conversions from TAPP to open repair, postoperative deaths. There were not less pain quicker mobility and shorter period of disability in the laparoscopic group (group A). Ten (15.6%) postoperative complications occurred in group A: local hematoma (6 cases, 9.3%), neuralgias (3 cases, 4.7%), urinary retention (1 case, 1.6%). Eight (12.1%) postoperative complications: hematomas (3 cases, 4.5%), urinary retention (3 cases, 4.5%), neuralgias (2 cases, 3%) occurred in group B. Differences were not significant. The current follow-up period is 36 months (15-54) in median. In both groups no recurrences occurred, but 3 patients in group B who were operated on for monolateral hernia (6.5%) discovered to be affected by contralateral hernia. The results of the present report suggest that TAPP does not appear to be associated with better results in terms of complications, pain or period of disability as compared to open tension free hernia repair, but the ability of the laparoscopic approach to expose otherwise-occult defects eliminated the risk of recurrences due to missed hernias.     

Risks and benefits of laparoscopic hernia-plasty (TAPP). 5 years experiences with 3,400 hernia repairs

In the present study, for the first time the aspects of risk, benefit and the costs of laparoscopic hernioplasty in the transabdominal technique with preperitoneal placement of a polypropylene mesh are examined prospectively in a very large group of patients with 3,400 hernia repairs. The median operation time was 45 min for unilateral primary hernias, 50 min for unilateral recurrent hernias and 76 min for bilateral hernias. The frequency of complications showed a significant dependence on the individual steps in the development of the method and the individual learning curve. The same is true for the rate of recurrency. Whereas initially the rate of serious complications was 2.75%, the rate of minor complications 11% and the rate of recurrences 4.5% the corresponding figures are at present 0.4%, 4.4% and 0.5%. Laparoscopic hernioplasty proved to be equally as effective in the treatment of primary hernias, recurrent hernias and bilateral hernias. The large number of 11 surgeons participating proves that laparoscopic hernioplasty can be learned and that even in a teaching hospital it can be performed safely, efficiently and cost-effectively.     

Laparoscopic inguinal herniorrhaphy: the new gold standard of hernia repair?

The surgical treatment of the common inguinal hernia has been one of the most analyzed and debated topics in medicine. Recently, with the success of laparoscopic cholecystectomy, interest in minimally invasive surgical techniques has led to it's application for inguinal hernia repair. Current laparoscopic herniorrhaphies are based on the principles of conventional open preperitoneal repairs and are classified into two types: 1) transabdominal preperitoneal repair (TAPP) and 2) totally extraperitoneal repair (TEP). Common advantages to both techniques include a decrease in postoperative pain, earlier return to normal activity, and improved cosmesis. Both laparoscopic techniques have the disadvantage of requiring general or regional anesthesia and increased procedural costs. Lastly, there is a concern that laparoscopic hernia repair has not been around long enough to know the risk of late recurrences. Laparoscopic herniorrhaphy, however, is a viable alternative to standard open inguinal hernia repair.     

Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary results

BACKGROUND: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias >/=4 cm2) is being used in a prospective, multicenter, long-term study. METHODS: Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7-10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients. RESULTS: In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5-731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively. CONCLUSIONS: Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery.     

Late mesh rejection as a complication to transabdominal preperitoneal laparoscopic hernia repair

BACKGROUND: The use of a mesh in transabdominal preperitoneal laparoscopic hernia repair (TAPP) caries the risk of late rejection or infectious complications related to the mesh. The aim of this study was to describe the extent of these complications. METHODS: We performed a retrospective study of 500 consecutive patients with TAPP for inguinal hernia. Results: Late mesh rejection was observed in three patients at 5-19 months after surgery. The mesh was removed via a suprapubic midline incision. At 3-4 month's follow-up, none of the patients had recurrence of the hernia, even though no hernia repair had been done. CONCLUSION: Late mesh rejection is a potential complication of TAPP and has to be considered when choosing the surgical method of hernia repair.     

Experience with 300 laparoscopic inguinal hernia repairs with up to 3 years follow-up

The long-term results of 300 laparoscopic inguinal hernia repairs are reported with 11 cases followed up more than 3 years, 104 cases more than 2 years, and 225 cases more than 1 year. There were five early failures owing to the use of too small a piece of mesh. There have been no long-term recurrences. The results indicate that transabdominal preperitoneal laparoscopic mesh repair of hernias is a satisfactory technique with a low recurrence rate and a low major complication rate (4%). Patients have found the procedure to be remarkably pain free and 51% have taken no analgesics after discharge from hospital. Of the patients, 78% returned to work within 2 weeks of the operation. These results suggest that laparoscopic hernia repair can be performed safely with excellent long-term results.     

Recurrent inguinal hernia: preferred operative approach

Inguinal herniorrhaphy remains one of the most common general surgical operations, with approximately 10 to 20 per cent performed for recurrence. Subsequent repairs provide considerable technical challenge, as well as substantially greater risk of developing further recurrence. Mesh repair is advocated by several specialized hernia centers, demonstrating re-recurrence rates less than 2 per cent. Detractors of this repair include cost, technical difficulty, and risk for infection. The purpose of this study was to compare results of mesh and nonmesh repairs for recurrent inguinal hernia, either using an anterior or posterior approach, at a large teaching institution. From January 1, 1985, to December 31, 1994, 146 patients underwent repair for recurrent inguinal hernia at the Veterans Administration Hospital at Memphis, Tennessee. Patients were stratified by type of repair: Lichtenstein (Mesh), open anterior (OA), Bassini, Marcy, McVay, Shouldice, and preperitoneal with or without mesh. Patient ages and weights were similar between groups. Mean operative time for Mesh repair (104 +/- 4 minutes) was longer than that for OA repairs (80 +/- 5 minutes, P < 0.05) or preperitoneal without mesh repairs (92 +/- 5 minutes, P < 0.05). Mesh-based posterior repairs had the longest operative times (116 +/- 5 minutes). Hospital stay averaged 2.8 +/- 0.3 days, similar among all groups. One wound infection (1.0%) occurred in patients undergoing Mesh repair, which required operative drainage. No patient required removal of mesh. Two patients in the Mesh group (5.9%) developed recurrence compared with four recurrences (18.0%) in patients undergoing OA repairs. Only one patient with a mesh-based posterior repair recurred (1.9%) compared to eight without mesh (21.6%, P < 0.01). Follow-up ranged from 2 to 12 years. Repair of recurrent inguinal hernia using either an anterior or posterior mesh repair technique, performed at a teaching facility, provides superior recurrence rates without increasing risk for infection or length of stay. Preperitoneal mesh based repair is the preferred technique.     

The medical demands of the special athlete

BACKGROUND AND AIMS: Before choosing between open and laparoscopic preperitoneal tension-free repair, a study comparing their safety and short-term outcome was needed. No randomised studies comparing the two hernia repair techniques have hitherto been published. MATERIAL AND METHODS: A prospective randomised study was carried out comparing laparoscopic transabdominal preperitoneal mesh herniorrhaphy (n = 24) to open preperitoneal mesh herniorrhaphy (n = 25). RESULTS: When comparing unilateral repairs, the mean operation time was significantly (P < 0.01) shorter in the open group (55 min) than in the laparoscopic group (66 min). Pain on movement (P < 0.05) and pain on coughing (P < 0.01) receded more rapidly in the laparoscopic group. The median time before return to work or normal activity was 7 days (range 1-60) in laparoscopic and 5 days (1-30) in open repair. There were five (21%) complications associated with the laparoscopic procedure, while the open procedure resulted in two (8%) complications. After a median follow-up of 18 months the recurrence rate in the laparoscopic group was 13% and in the open group 8%. CONCLUSIONS: In this study the open method was associated with fewer complications and recurrences than the laparoscopic technique. Despite the decreased postoperative discomfort after laparoscopic repair, there was no significant difference in median time before return to work or normal activity. These results together with the higher cost of the laparoscopic procedure suggest that the open method is more suitable at least for unilateral hernias.     

New possibility in inguino-femoral hernia repair: laparoscopic herniaplasty

The development of minimally invasive surgery brought up the challenge: to repair the frequent inguino-femoral hernias laparoscopically. The authors performed 65 laparoscopic hernioplasties in one year: "transabdominal preperitoneal" technique was used in 61 cases und "intraperitoneal onlay mesh" in 4 cases. Fifty-three patients were operated on, 12 of them had bilateral hernias. Recurrent hernia was the indication in 22 patients (34%). The average operating time was 102 and 144 minutes in the unilateral and the bilateral cases, respectively. There was no wound infection, or general complication. Spontaneously dissolving seroma/hematoma of the spermatic cord was noticed and detected by ultrasound in 5 patients (7.7%). The neuralgia caused by the irritation of the nerves of the region in 4 patients (6.1%) disappeared without sequels after treatment with vitamins B. The 2 early recurrences (3.2%), considered to be caused by technical inexperience, these patients were treated successfully with the "intraperitoneal onlay mesh" technique. In the authors' opinion there are definite advantages of laparoscopic hernioplasty, namely the minimal postoperative pain, early mobilization, shorter hospital stay and early restoration of full physical activity (in 1-2 weeks) as well as the known disadvantages of this technique (narcosis, longer operative time, intraperitoneal procedure, higher costs).     

Thyrotoxicosis presenting as a life threatening hypokalaemic paralysis: investigation of the Na/K pump in isolated leucocytes

Laparoscopic femoral herniorrhaphy using a preperitoneal plug and patch appears to be a feasible laparoscopic approach to femoral hernia. A modified preperitoneal femoral hernia repair with mesh and resection of incarcerated small bowel has been successfully completed under laparoscopic guidance in a 64-year-old patient with incarcerated femoral hernia. To our knowledge, this is the first such case reported in the United States. With further experience, laparoscopic femoral herniorrhaphy could provide a viable alternative to the standard treatment of femoral hernia.     

Laparoscopic repair and groin hernia surgery

Over the past 15 years, laparoscopic herniorrhaphy has made the transition from an experimental to a proven procedure. With increasing laparoscopic skills in the surgical community, many surgeons are now faced with the question of when to recommend laparoscopic herniorrhaphy to their patients. A surgeon's best hernia repair is the one with which they have had the greatest experience. This results in the lowest recurrence and complication rate in his or her hands. Certainly, simple, unilateral hernias and bilateral hernias can be repaired with either anterior or laparoscopic techniques. Many times, laparoscopic herniorrhaphy is too much surgery for a young patient with a unilateral hernia. In such a case, repair is best performed with the patient under local anesthesia. Also, young patients in whom it is advantageous to avoid mesh should not undergo laparoscopic herniorrhaphy. The authors prefer laparoscopic TEP herniorrhaphy in patients with recurrent hernias, bilateral hernias, and unilateral hernias with a suspected contralateral hernia. There is also a consensus that patients with multiple recurrent hernias in whom a preperitoneal repair is appropriate are best served with a laparoscopic repair. Surgeons without advanced laparoscopic skills or without the time to develop the skills necessary to perform laparoscopic herniorrhaphy should consider referring patients with recurrent hernias to surgeons with experience in TEP. TEP is preferable to TAPP because of its lower complication and recurrence rates and in the authors' hands is the "best repair." TAPP should be reserved for patients with prior lower abdominal wall incisions that make the dissection of the peritoneum from the underside of the incision impossible. Patients who cannot tolerate general anesthesia or who have had extensive lower abdominal surgery should not undergo laparoscopic herniorrhaphy. Complication and recurrence rates, although initially higher than traditional repairs, have now fallen to equal or lower levels at centers experienced in laparoscopic techniques. Prospective randomized trials prove that when patients are selected properly and surgeons are adequately trained and proctored, laparoscopic herniorrhaphy can be performed with acceptably low incidences of recurrence and complications.     

Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy. Early results

BACKGROUND: In February 1993 a prospective randomized multicenter trial was initiated to compare laparoscopic transabdominal preperitoneal hernioplasty to Shouldice herniorrhaphy as performed by surgeons of nonspecialized clinics. METHODS: Until January 1994, 87 patients with 108 hernias took part in the trial (43 Shouldice and 44 laparoscopic repairs). RESULTS: The laparoscopic procedure took significantly longer than did the open operation but caused less pain as measured by pain analogue score and consumption of paracetamol and narcotics. The postoperative complication rate was 26% in the open and 16% in the laparoscopic group. The patients in the laparoscopic group were discharged earlier and their convalescence was shorter than after open hernia repair. There has been one early recurrence in the laparoscopic and two in the open group to date with a mean follow-up of 201 days. CONCLUSIONS: Laparoscopic hernia repair causes less pain than the conventional operation and enables the patient to return to full work and usual activities earlier. The recurrence rate will not be known for 5 years.     

Chronic inguinal pain after transperitoneal mesh implantation. Case report of net shrinkage

The implantation of a mesh is an essential step in laparoscopic inguinal hernia surgery. We present the case of a 22-year-old man who developed an unspecific and refractory syndrome of inguinal pain after a TAPP procedure for a primary inguinal hernia. Repeated reoperation for removement of clips and nerve transection were unsuccessful. By a transinguinal approach, 18 months after the first operation we removed a preperitoneal Prolene mesh which had shrunk and folded to 30% of its original size. The problem of biocompatibility of meshes currently used in inguinal hernia surgery is discussed.     

Strength and functional recovery following repair of flexor digitorum superficialis in zone 2

Since 1989 we have performed 21 endoscopic hernia repairs in 19 female patients. One recurrent hernia occurred 3 months after laparoscopic preperitoneal patch repair using a single layer of resorbable mesh. Hernioscopy was developed as the transcutaneous endoscopic CO2-gas dissection and subsequent inspection of the preperitoneal hernial sac. Hernioscopic stuffing of the preperitoneal hernial sac using resorbable patch material was performed in seven direct inguinal hernias and in one femoral hernia. Postoperative pain was minimal and convalescence was short. No recurrent hernia occurred during a 1-9-month follow-up.     

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair

BACKGROUND: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). METHODS: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. RESULTS: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. CONCLUSIONS: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced.     

Laparoscopic repair of recurrent ventral hernias

Break down after repair of recurrent ventral hernias can exceed 50 per cent. Laparoscopic techniques offer an alternative. This study evaluated the efficacy of the laparoscopic approach for recurrent ventral hernias. A retrospective review on all patients with a recurrent ventral hernia who underwent laparoscopic repair at our institution from August 1995 to June 1997 was performed. Demographic, operative, postoperative, and follow-up data were collected. Thirty-one patients underwent an attempted laparoscopic ventral hernia repair. Sixteen were for recurrent hernias; 15 were successfully repaired laparoscopically. The patients were typically obese (mean body mass index, 30 kg/m2), had an average of 2.4 previous open repairs (range, 1-7), and six patients had previously placed intra-abdominal mesh. An average of 3.5 (range, 1-16) defects were found per patient with a mean total hernia size of 130 cm2 (6-480 cm2). In all cases, expanded polytetrafluoroethylene mesh (average, 299 cm2) was secured with transabdominal sutures. Postoperatively patients required an average of 19 mg of narcotics (MSO4 equivalent). Bowel function returned in 1.7 days. Length of stay averaged 2.0 days (1-4 days). There were two complications: cellulitis, which resolved with antibiotics, and skin break-down, which required mesh removal. With follow-up averaging 18 months (7-29 months), there is one recurrence; the case in which the mesh was removed. Laparoscopic repair of recurrent ventral hernia seems promising. Decreased hospital stays, postoperative pain, wound complications, and a low rate of recurrence are benefits of this technique.     

Research collaboration in parasitology between Indonesia and Australia

Today abdominal wall defect repair can't prescind from the use of prosthetic materials. Inguinal, femoral and incisional hernias represent more frequent events in which, only using prosthetic materials is it possible to perform "tension-free" repair. Prosthetic repairs "agree with" abdominal, wall physio-pathology, guarantee results and prevent recurrences. Permanent biomaterials like polypropylene and dacron mesh deserve special attention for their distinctive features are suitable for abdominal wall defect repair. Selection of material is an important step according to surgical technique and to avoid complications; the most alarming of which is a possible infection. However the average incidence of infection on prosthesis is about 0.5%. While infection risk is really scarce, the benefits of prosthetic repairs are clear: the recurrence rate of traditional hernia repairs is about 33% and 0-0.7% in prosthetic repairs. Likewise the recurrence rate for traditional incisional hernia repair is between 14% and 50%, whereas in prosthetic repairs it is 0-4.5%. Therefore it is necessary to use prosthesis for the following two reasons: firstly to avoid tension on the suture line, the prime cause of recurrence, and secondly to increase formation of collagen fibres on the transversalis fascia that appears histologically and biochemically altered. The authors report their experience of 660 prosthetic repairs, 600 for hernia and 60 for incisional hernia, performed, in the period April 1992-December 1994, at the General Surgery Department in San Giovanni Valdarno Hospital. The surgical techniques used were "tension-free" and "sutureless" and the prosthesis laid down always a polypropylene mesh. Complications only occurred in 33 patients, particularly 4 cases of infection (0.6%) however mesh remove was not required. The follow-up until today evidenced only two early recurrences owing to our technical mistakes in the beginning of our experience. For incisional hernia repair we laid down a giant dacron mesh on preperitoneal space. No complications were registered. The average stay in hospital was 5 days and follow-up showed no recurrence. The use of prosthetic materials in abdominal wall defect repair expressed large benefits with evident and clear reduction in recurrence rate. Traditional techniques produce tension on the suture line and high percentage of early and late recurrences since an essential surgical principle is transgressed. In fact traditionally repair has been accomplished by approximation of anatomical structures, that are not normally in apposition and by utilization of defective tissue. Metabolic alteration involving collagen turnover is evident in these patients. The answer to this problem is prosthetic repair. At present there is no ideal prosthesis, however the surgeon can use several suitable synthetic materials. The selection of prosthetic materials is a fundamental step also considering the possible infection; that however develops rarely. In conclusion the authors think that mesh repairs represent an overcoming of traditional surgical techniques in abdominal wall defect repair.     

Effect of starvation on organ blood flow in the senescent rat

Since the first true hernioplasty performed by Edoardo Bassini more than 100 years ago (1884) all surgical reconstruction techniques have shared a common defect i.e. tension on suture line. This is the first etiologic factor of recurrent hernia. On the contrary by the use of modern prosthetic materials (mesh and plug) it is now possible to marriage all hernia repairs without distorting normal body anatomy and avoid undesirable tensions. The technique proposed is simple, efficient, characterized by a rapid performing procedure, giving way to an excellent clinical outcome: postoperative pain relief permitting the patient to resume in a short time his normal physical activities. In this paper the authors present their experience in wall defects reconstruction by means of outpatient surgery and in general anesthesia in the period spanning from 1994 to 1996. Five different types of hernia mesh in hernioplasty procedures were evaluated and used.