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, 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.     

Feasibility and short-term results of the "plug" technique in inguinal hernia. A prospective evaluation

The aim of this prospective study was to assess the feasibility and postoperative outcome of the "plug" technique in inguinal hernia. One hundred and forty-six consecutive patients were operated for 151 hernias. A plug was applied in 131 cases (86.8%). The Lichtenstein technique was used in 20 cases (13.2%) because of a wide weakness of the posterior wall. Eleven (7.3%) postoperative benign complications occurred. No severe complications were observed and no patient was reoperated. The mean duration of oral analgesia was 2.7 (0-10) days. Mean durations of postoperative hospital stay, time off work and cessation of normal activities were 1.2 (0-4) days, 18.1 (1-37) days and 5.8 (1-18) days, respectively. In conclusion, the "plug" technique is feasible in a wide range of hernias and allows a short hospital stay and an early return to normal activity.     

Colonoscopic findings in Crohn''s disease--reproducible, but of questionable benefit

Between January, 1991 and December, 1993, 208 subjects with monolateral and 19 with bilateral inguinal hernia were submitted to herniorrhaphy. Thirty-four were recurrent hernias. All but one bilateral hernias were treated at the same time. Eight cases were operated in emergency condition for acute strangulated hernia. Two-hundred and ten operations were performed under local, 17 under general and 1 under spinal anesthesia. Herniorrhaphy was performed in 14 cases with the Bassini and in 38 with the Shouldice technique. In 191 instances the "tension-free" and in 3 the "plug" techniques were adopted utilizing a polypropylene mesh. Following local anesthesia 13 episodes of bradycardia with hypotension were recorded during the operation and 4 in the early postop period. There were no general complications. Two elderly patients developed urinary retention following general anesthesia. Local complications included 6 (2.4%) cases of infection and 4 (1.6%) cases of hematoma of the wound, and 5 (2.0%) cases of edema with infiltration of the cord. Percentage of follow-up at 1, 2 and 3 years was 96, 95, and 93 percent respectively. Five recurrences were recorded: in 1 case following Bassini repair (7.6%), in 2 following Shouldice (5.6%), and in 2 following tension-free (1.5%). Local anesthesia has been confirmed to be well accepted by the patients, effective an safe, especially in the elderly patients with high operative risk. Similarly, the tension-free hernioplasty has been confirmed as a simple, easily reproducible technique, followed by less pain and disability as compared with other types of herniorrhaphies, and more effective mainly in the treatment of recurrent hernia.     

Tension-free hernioplasty: technical remarks and personal experience

The authors report their experience with 463 tension free hernioplasty procedures for inguinal and femoral hernias. The surgical technique included the insertion of both a polypropylene plug and a polypropylene mesh, and was carried out mostly in local anesthesia (84.2%) using bupivacaine 0.25% for ileoinguinal and ileohypogastric blockage and mepivacaine 0.5% for local infiltration. There was no major intraoperative complication; local postoperative complications were rare (10%) and easily managed; postoperative pain was frequently observed (66%), though mild and transient; resumption of working activity occurred within a month in 96.6% of cases; there were only 3 post-operative recurrences (respectively, at 1, 6 and 12 months). The authors conclude that the tension free hernioplasty is a simple, rapid, low-cost and effective technique, easily performed under local anesthesia.     

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.     

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.     

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.     

The nuclear scaffold structures and plasmid DNA replication in the cells of higher eukaryotes]

In a prospective randomized trial comparing the totally preperitoneal (TPP) laparoscopic approach and the Stoppa procedure (open), 100 patients with inguinal hernias (Nyhus IIIA, IIIB, IV) were followed over a 3-year period. Both groups were epidemiologically comparable. In the laparoscopic group, operating time was significantly longer (p = 0.01), but hospital stay (3.2 vs. 7.3 days) and delay in return to work (17 vs. 35 days) were significantly reduced (p = 0.01). Postoperative comfort (less pain) was better (p = 0.001) after laparoscopy. In this group, morbidity was also reduced (4 vs. 20%; p = 0.02). The mean follow-up was 605 days, and 93% of the patients were reviewed at 3 years. There were three (6%) recurrences after TPP, especially at the beginning of the surgeon's learning curve, versus one for the Stoppa procedure (NS). For bilateral hernias, the authors suggest the use of a large prosthesis rather than two small ones to minimize the likelihood of recurrence. In the conditions described, the laparoscopic (TPP) approach to inguinal hernia treatment appears to have the same long-term recurrence rate as the open (Stoppa) procedure but a real advantage in the early postoperative period.     

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.     

Formulaic methods of estimating calorie requirements in mechanically ventilated obese patients: a reappraisal

We reviewed 410 cases, 365 males and 45 females, mean age 64 years, of inguinal and femoral hernia, from 1/1/1991 to 31/12/1994, repaired with Lichtenstein and Trabucco techniques. Recurrent hernias repaired were 36 (8,8%). Local anesthesia was used in 82% and follow-up has ranged from 6 months to 4 years. The meshes used are made with a single layer of polipropylene and the Trabucco plugs T1 were made by hand at the operating table. In our experience these two techniques are simple, but is very important, before application of the mesh, a correct dissection of inguinal region. We made a complete excision of cremasteric fibers preservig, if possible, the genital branch of the genitofemoral nerve. The transversalis fascia is introflected and sutured in direct hernia repair or when there are a loss of tissues. The preliminary results obtained with the "tension free" hernioplasty are satisfying. The most important complications were 9 hematomas and an important and persistent inguinal neuralgia in 1 case. There were no recurrences, but we must considered the short follow-up period.     

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.     

Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair

BACKGROUND: Inguinal hernias can be repaired by laparoscopic techniques, which have had better results than open surgery in several small studies. METHODS: We performed a randomized, multicenter trial in which 487 patients with inguinal hernias were treated by extraperitoneal laparoscopic repair and 507 patients were treated by conventional anterior repair. We recorded information about postoperative recovery and complications and examined the patients for recurrences one and six weeks, six months, and one and two years after surgery. RESULTS: Six patients in the open-surgery group but none in the laparoscopic-surgery group had wound abscesses (P=0.03), and the patients in the laparoscopic-surgery group had a more rapid recovery (median time to the resumption of normal daily activity, 6 vs. 10 days; time to the return to work, 14 vs. 21 days; and time to the resumption of athletic activities, 24 vs. 36 days; P<0.001 for all comparisons). With a median follow-up of 607 days, 31 patients (6 percent) in the open-surgery group had recurrences, as compared with 17 patients (3 percent) in the laparoscopic-surgery group (P=0.05). All but three of the recurrences in the latter group were within one year after surgery and were caused by surgeon-related errors. In the open-surgery group, 15 patients had recurrences during the first year, and 16 during the second year. Follow-up was complete for 97 percent of the patients. CONCLUSIONS: Patients with inguinal hernias who undergo laparoscopic repair recover more rapidly and have fewer recurrences than those who undergo open surgical repair.     

Double-blind randomized comparative study of nicergoline naftidrofuryl on the quality of life in chronic obliterative arteriopathy of lower limbs with intermittent claudication]

There are presented nine patients with spigelian hernia operated on between 1964 and 1996 (33 years interval). These patients represent 0.19% of the totality of the patients operated for different hernias in the same period. The sex ratio female/male was 7/2. The medium age of the patients was 55 years old +/- 12-18, the extremes being 37 and 67 years. To all the patients the hernia was located on the right side of the abdomen. The main associated disease, the degree III and IV obesity was present in 8 from 9 cases. In 3 cases (33%) the evolution was complicated by incarceration of the big epiploon and to one patient (11%) by partial strangulation of a jejunum ansae, Richter's type. Two patients with very large, nonreducible hernias created possibilities of confusions with abdominal tumors. Generally, the diagnosis was established only on clinical basis. All the patients were operated on (the Bachy techniques with direct approach) without immediate or late complications (there were no recurrences).     

From Bassini to tension-free mesh hernia repair. Review of 1409 consecutive cases

The short and long-term results of traditional and tension-free inguinal hernia repairs have been assessed in three surgical units. In order to standardise the results, hernias were classified according with Nyhus. There were 109 type I, 311 type II, 854 type III, and 125 type IV hernias. Follow-up was possible in 1201 patients (1249 hernia repairs). Postoperative course, postoperative pain, and recurrences were analysed. Recurrences ranged from 0.7% up to 9.3%. The tension-free methods of repair provided the most important advantages in term of low recurrence rate and early return to work even if, in our series, recurrences resulted mainly related to the type of hernia than to the type of repair. The Authors conclude that any hernia repair should be sized to the type of hernia defect in order to avoid over-treatment and abusive placing of a foreign body such as polypropylene mesh.     

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.     

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).     

Thirty-six cases of obturator hernia: does computed tomography contribute to postoperative outcome?

Obturator hernia is relatively rare and occurs mostly in elderly, thin, multiparous women. Recent reports have highlighted the importance of pelvic computed tomography (CT) for the preoperative diagnosis. Thirty-six patients with an obturator hernia operated in our hospital were divided retrospectively into two groups (group A: 18 operations from 1973 to 1986, before we used CT; group B: 18 CT cases from 1987 to 1995). Preoperative diagnoses, operative procedures, and postoperative course were reviewed. No statistically significant differences were found between groups A and B in terms of patient characteristics. Rates of accurate preoperative diagnoses were significantly higher in group B: 39% (7/18) in group A and 78% (14/18) in group B (p = 0.018). The intraoperative findings, occurrence of postoperative complications, and overall mortality rates were similar between the two groups. There were four postoperative deaths (mortality rate 11%). Three of four patients who died had panperitonitis because of small bowel perforation. The correct preoperative diagnosis of obturator hernia was facilitated by CT of the pelvis, but it has no impact on patient outcome. Early diagnosis and surgical intervention are essential for this rare entity.     

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.