Cephalosporin vs penicillin

Smaller individual series on the outcome of laparoscopic hernioplasty techniques have been reported. This study reports on the complications of 3,229 laparoscopic hernia repairs performed by the authors in 2,559 patients. The TAPP (transabdominal preperitoneal) technique was the most frequently performed: 1,944 (60%). The totally preperitoneal technique was performed 578 (18%) times. The IPOM (intraperitoneal onlay mesh) repair was performed 345 (11%) times. The plug-and-patch technique was used 286 (9%) times and simple closure of the hernia defect without mesh was used in 76 (2%) repairs. Overall, there were 336 (10%) complications: 17 (0.5%) major and 265 (8%) minor. There were 54 (1.6%) recurrences, with a mean follow-up of 22 months. The TAPP technique had 19 (1%) recurrences and 141 (7%) complications. There were four bowel obstructions in this subgroup from herniation of small bowel through the peritoneal closure and trocar sites. The totally preperitoneal technique had no recurrence and 60 (10%) complications. The IPOM group had 7 (2%) recurrences and 47 (14%) complications. The plug-and-patch technique had 26 (9%) recurrences and 24 (8%) complications. The simple closure of the internal ring had 2 (3%) recurrences and 10 (13%) complications. Laparoscopic hernioplasty is not without complications. Laparoscopic hernioplasty is not without complications. Training, experience, and attention to technique will prevent some of these complications.     

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.     

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.     

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.     

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.     

Matrix metalloproteinase expression in rat pancreatic islets

OBJECTIVE: To determine whether the type of prosthetic material and technique of placement influenced long-term complications after repair of incisional hernias. DESIGN: Retrospective cohort analytic study. SETTING: University-affiliated hospital. PATIENTS: Two hundred patients undergoing open repair of abdominal incisional hernias with prosthetic material between 1985 and 1994. INTERVENTIONS: Four types of prosthetic material were used and placed either as an onlay, underlay, sandwich, or finger interdigitation technique. The materials were monofilamented polypropylene mesh (Marlex, Davol Inc, Cranston, RI), double-filamented mesh (Prolene, Ethicon Inc, Somerville, NJ), expanded polytetrafluroethylene patch (Gore-Tex, WL Gore & Associates, Phoenix, Ariz) or multifilamented polyester mesh (Mersilene, Ethicon Inc). MAIN OUTCOME MEASURES: The incidence of recurrence and complications such as enterocutaneous fistula, bowel obstruction, and infection with each type of material and technique of repair were compared with univariate and multivariate analysis. RESULTS: On univariate analysis, multifilamented polyester mesh had a significantly higher mean number of complications per patient (4.7 vs 1.4-2.3; P<.002), a higher incidence of fistula formation (16% vs 0%-2%; P<.001), a greater number of infections (16% vs 0%-6%; P<.05), and more recurrent hernias (34% vs 10%-14%; P<.05) than the other materials used. The additional mean length of stay to treat complications was also significantly longer (30 vs 3-7 days; P<.001) when polyester mesh was used. The deleterious effect of polyester mesh on long-term complications was confirmed on multiple logistic regression (P=.002). The technique of placement had no influence on outcome. CONCLUSION: Polyester mesh should no longer be used for incisional hernia repair.     

Complications of laparoscopic paraesophageal hernia repair

The complications of laparoscopic paraesophageal hernia repair at two institutions were reviewed to determine the rate and type of complications. A total of 76 patients underwent laparoscopic paraesophageal hernia repair between December 1992 and April 1996. Seventy-one of them had fundoplication (6 required a Collis-Nissen procedure). Five patients underwent hernia reduction and gastropexy only. There was one conversion to laparotomy. Traumatic visceral injury occurred in eight patients (11%) (gastric lacerations in 3, esophageal lacerations in 2, and bougie dilator perforations in 3). All lacerations were repaired intraoperatively except for one that was not recognized until postoperative day 2. Vagus nerve injuries occurred in at least three patients. Three delayed perforations occurred in the postoperative period (4%) (2 gastric and 1 esophageal). Two patients had pulmonary complications, two had gastroparesis, and one had fever of unknown origin. Seven patients required reoperation for gastroparesis (n = 2), dysphagia after mesh hiatal closure of the hiatus (n = 1), or recurrent herniation (n = 4). There were two deaths (3%): one from septic complications and one from myocardial infarction. Paraesophageal hernia repair took significantly longer (3.7 hours) than standard fundoplication (2.5 hours) in a concurrent series (P <0.05). Laparoscopic paraesophageal hernia repair is feasible but challenging. The overall complication rate, although significant, is lower than that for nonsurgically managed paraesophageal hernia.     

Postoperative incisional hernias: intra- or extraperitoneal prosthesis implantation?

STUDY AIM: The aim of this retrospective study concerning the repair of postoperative incisional hernia using Dacron mesh was to compare results according to the extra- or intraperitoneal mesh position in order to assess the respective indications of each option. MATERIALS AND METHODS: From January 1985 to December 1996, 172 patients (mean age: 61.3 years) were operated on using Dacron mesh extraperitoneally (n = 99) or intraperitoneally located (n = 73). For statistical analysis, both groups were compared using Chi square test or Fisher's test. RESULTS: There were no postoperative deaths in the group with extraperitoneal mesh and two postoperative deaths in the group with intraperitoneal mesh. There were no significant differences when results comparing parietal complications (sepsis: 2% vs 2.7%, pain: 9.1% vs 16.9%), secondary intestinal disorders (2% vs 4.2%) and recurrence rate (4% vs 5.6%) were assessed between extraperitoneal and intraperitoneal mesh. Recurrences were related to pareital infection treated by partial removal of the mesh (n = 2) or to the lateral detachment of the mesh (n = 6). CONCLUSIONS: In the group of patients receiving extraperitoneal mesh there were no postoperative deaths and morbidity was low (this technique is generally used in the treatment of large incisional hernia). In the group of patients receiving intraperitoneal mesh, similar parietal and general complications were observed. But the risk of serious complications and postoperative death is higher; this technique must be limited to the most serious incisional hernia and to high risk patients.     

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.     

Double-gracilis anorectal neosphincter: technique of reconstruction after necrosis of the distal part of the muscles

BACKGROUND: The Lichtenstein tension-free repair has become the standard method for repairing inguinal hernia in many surgical units. This study compared two methods of mesh fixation. METHODS: Fifty men undergoing unilateral primary Lichtenstein inguinal hernia repair under general anaesthesia were randomized into two groups. In the control group polypropylene mesh was secured with 2/0 polypropylene sutures and the skin closed with subcuticular 3/0 polydioxanone. In the study group polypropylene mesh was secured with skin staples and the skin was closed with staples from the same staple gun. Duration of the operation was recorded. Early follow-up was achieved by patient review at 6 weeks and postal questionnaire at 12 weeks. RESULTS: The operation was significantly shorter when staples were used (median 20 min 0 s versus 29 min 30 s, P < 0.001). There was no significant difference in the incidence of postoperative complications or pain score. The study group reported earlier return to normal activity (4 weeks 0 days versus 6 weeks 2 days, P < 0.01) although there was no difference in the time taken to return to work or driving. CONCLUSION: The use of skin staples to secure mesh in the Lichtenstein inguinal hernia repair significantly reduced the duration of the operation and was as effective as conventional mesh fixation with polypropylene in the short term.     

Mesh hernioplasty using a stapler

BACKGROUND: The recent development of laparoscopic hernioplasty has evoked extensive re-examination of the safety and effectiveness of using synthetic mesh materials in hernia surgery. We have investigated the efficacy of anterior stapling mesh repair in the treatment of inguinal hernia. METHODS: From July 1993 to June 1994, a modified open mesh hernioplasty using staples for anchorage has been performed in 127 patients. RESULTS: The mean age of patients was 61.4 +/- 13.0 years. Over 90% of them were operated on under local anaesthesia. The operation time ranged from 30 to 95 min with a median of 39 min. Only sixteen patients (12.6%) required postoperative parenteral analgesics and the median time for resuming daily activities was 7 days. Apart from two patients with reactionary haemorrhage, there was no other significant complication observed. Only one recurrence was encountered over the 26-month median follow-up period. CONCLUSIONS: We conclude that the modified mesh hernia repair with a stapling device is a feasible, inexpensive and safe procedure that is well tolerated under local anaesthesia by most patients.     

Lichtenstein inguinal hernia repair in a primary healthcare setting

BACKGROUND: Given the generally accepted poor outcome of inguinal hernia repair when using nylon darn, and the recent interest in low-tension mesh repair, an attempt was made to demonstrate the feasibility, outcome and patient perception of providing Lichtenstein inguinal hernia repair, using local anaesthesia, wholly within the primary healthcare sector. METHODS: A prospective study reviewed clinical outcome and patient perception in 100 adults referred with inguinal hernia only. No selection was made regarding age, sex, American Society of Anesthesiologists status or previous repairs. Recurrence, pain, infection, return to full function and associated complications were assessed at 24 h, 1 and 6 weeks, and 1 year. Local Community Health Councils assessed patient perception. RESULTS: In the first 100 patients (age range 21-83 (mean(s.d.) 60(14.7)) years; 58 of employable age; 92 men; ten recurrent hernias), no recurrences have occurred at 1 year. Infection rate was 3 per cent. Pain was maximal in the first 24-48 h (median visual analogue scale 5, range 0-10) and reduced rapidly (median 1) at 1 week. Mean time to return to work or full normal activity was 8 days. Some 85 operations were performed within 1 month of diagnosis. In all, 86 patients returned the patient satisfaction questionnaire and 98 per cent of these were 'very pleased' with the service. CONCLUSION: In highly motivated primary healthcare centres, inguinal hernia repair can be undertaken effectively, providing high patient satisfaction, minimal complications and low recurrence rates using the Lichtenstein technique.     

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.     

Management of complicated incisional hernias with underlay-technique implanted polypropylene mesh. An effective technique in French hernia surgery

Incisional hernia repair with conventional techniques (simple closure, Mayo-technique) is associated with unacceptable recurrence rates of 30-50%. Therefore, surgical repair using different prosthetic biomaterials is becoming increasingly popular. Further to favourable results by French hernia surgeons, we studied the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias. METHOD: After preparation and excision of the entire hernia sac, the posterior rectus sheath is freed from the muscle bellies on both sides. The peritoneum and posterior rectus sheaths are closed with a continuous looped polyglyconate suture. The prosthesis used for midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The anterior rectus sheath is closed with a continuous suture. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. RESULTS: Between January 1996 and August 1997 we performed a total of 33 incisional hernia repairs (14 primary hernias, 19 recurrent hernias) using this technique (16 women, 17 men, mean age 56.19 +/- 12.92 years). Local complications occurred in four patients (12%): superficial wound infection (n = 2), postoperative bleeding, requiring reoperation (n = 1), minor hemato-seroma (n = 1). One patient suddenly died on the 3rd post-operative day from severe pulmonary embolism (mortality 3%). Twenty-two patients with a minimum follow up to 6 months were re-examined clinically. The average follow-up time for this group was 9 months (range 6-17 months). To date no recurrent hernias have been observed. There were only minor complaints like "a feeling of tension" in the abdominal wall (n = 3) and slight pain under physical stress (n = 6). CONCLUSIONS: The use of prosthetic mesh should be considered for repair of large or recurrent incisional hernias, especially in high-risk patients (obesity, obstructive lung disease) and complicated hernias. The aforementioned technique of underlay prosthetic repair using polypropylene mesh fixed onto the posterior rectus sheath allows for anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates.     

Day-case laparoscopic hernia repair

Some 114 patients (median age 52 years) underwent laparoscopic hernia repair as a day-case procedure. Twenty-one patients had bilateral and 11 recurrent hernias. Some 113 patients underwent transabdominal preperitoneal mesh repair but one required conversion to open operation. Mean operating time was 24 min for unilateral and 38 min for bilateral repair. In an operating session of 3.5 h, up to five patients (mean 4.4) underwent surgery and as many as seven hernias were repaired. More than 10 per cent of patients were found to have a previously undiagnosed hernia on the opposite side. A total of 111 patients were discharged home on the day of surgery. Major complications included one omental bleed and one small bowel obstruction. Seroma was the commonest minor complication and occurred in 7 per cent of patients. More than 35 per cent of patients needed no postoperative analgesia. To date there has been one recurrence (follow-up range 2-18 months).     

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.     

Mesh configurations in laparoscopic extraperitoneal herniorrhaphy. A comparison of techniques

BACKGROUND: Laparoscopic total extraperitoneal (TEP) hernia repair utilizes slit mesh that is placed around the spermatic cord to secure the prosthesis and prevent recurrence. Because of concern that encircling of the cord might increase pain and morbidity, we compared patients with mesh repairs using encircled and nonencircled techniques. METHODS: The 191 male patients who underwent bilateral TEP repairs were divided into three groups. In 100 consecutive patients (group A), the slit mesh was closed around both spermatic cords; in 56 patients (group B), the slit mesh was tucked under the spermatic cords but not closed; in 35 consecutive patients (group C), the slit was closed around one cord and tucked under the other, in a randomized fashion. RESULTS: The groups had similar operative times (A: 83 +/- 25 min; B: 79 +/- 21; C; 77 +/- 24), use of pain medication (A: 2.7 +/- 2.5 days; B: 2.4 +/- 1.9; C: 3.1 +/- 2.4), and recovery before return to work (A: 7.9 +/- 7.0 days; B: 8.2 +/- 6.1; C: 6.7 +/- 4.8). The incidence of indirect hernias was similar in all groups. Complication rate was 20% in A, 20% in B, and 14% in C (p = NS). Chronic pain was more frequent in A (A: 6, B: 0, p = 0. 06). In group C, fluid collections were more common on the closed side (closed: 3, tucked: 0; p = 0.08). There were no recurrences in any group. CONCLUSIONS: Closing the slit around the spermatic cord in laparoscopic inguinal hernia repair is not essential for prevention of early recurrence. Fluid collections tended to be more frequent when the mesh was closed around the cord, and chronic pain was more frequent in the group with closed mesh bilaterally.     

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.