Perioperative quality assessment of varicose vein surgery : Commission for quality assessment of the German Society for Vascular Surgery.

PURPOSE: An estimated 350,000 varicose vein (VV) surgical procedures are performed in Germany each year, with annual treatment costs amounting to about 800 million Euro. To evaluate the outcome quality of this treatment, we examined the intraoperative and postoperative complication rates on record in the VV surgery quality assessment (QA) registry of the German Society for Vascular Surgery (GSVS). METHODS: Data on 89,647 patients (27,463 men, 62,184 women; average age 52.8 years, range 15-96 years) collected in the GSVS varicose surgery QA registry between 2001 and 2009 were analyzed. In these patients, 95,214 surgical procedures were performed on 105,296 limbs. Complication rates were correlated with the type of VV surgical procedure, with whether surgery was performed on an inpatient or outpatient basis, and with the CEAP classification (C stage) and American Society of Anaesthesiologists' (ASA) stage at the time of surgery. Statistical analyses were performed using a chi-square test, a Cochrane-Armitage test, and an odds ratio calculation. RESULTS: Intraoperative and postoperative complication was low (0.18 and 0.43 %, respectively), being the lowest for radiofrequency ablation (0.25 %) but not differing significantly from those for endovenous laser therapy and high ligation and stripping. General complications occurred in 0.67 % of outpatients and in 0.25 % of inpatients, a highly significant statistical difference (p < 0.0001, chi-square test). With regard to C stage, the higher the stage, the higher the local complication rate. A clear correlation was also found between preoperative ASA stage and postoperative complication rates: for ASA stages I and II, the complication rates were 0.2 and 0.5 %, respectively, increasing for ASA stage III to 1.2 % and for ASA IV to 2.2 %. The differences between the ASA classes were highly statistically significant (p < 0.0001, Cochrane-Armitage test) CONCLUSIONS: Outcome quality as reflected in the intraoperative and postoperative complication rates was very good for all patients undergoing inpatient or outpatient VV surgery. Data from the GSVS QA registry shows that VV surgery is performed with very good perioperative results in specialized centers in Germany.

Early postoperative and one year results of a randomized controlled trial comparing the impact of extralight titanized polypropylene mesh and traditional heavyweight polypropylene mesh on pain and seroma production in laparoscopic hernia repair (TAPP).

BACKGROUND: Today the main goals of inguinal hernia repair are maximum postoperative comfort and a minimal rate of chronic pain. This randomized trial compares these parameters after laparoscopic hernia repair (TAPP) using an extralight titanized polypropylene mesh (ELW group) TiMesh(®) 16 g/m(2) without any fixation with those using a standard heavyweight mesh (HW) Prolene 90 g/m(2) fixed in a standardized way with two absorbable sutures. METHODS: Three hundred patients with an inguinal hernia and a defect diameter ≤3 cm were included in the trial. Patients were assessed for pain, foreign body sensation, and physical activities preoperatively, early postoperatively, at 4 weeks, 6 months, and 1 year by questionnaire and were examined clinically. Postoperatively, seroma formation was measured by ultrasound. RESULTS: One year after TAPP, the frequency of chronic pain was not greater than 3%, with no difference between the two mesh groups; in no patient was intensity of pain higher than VAS 40. In the early postoperative period, 40% of the patients in the titanized ELW group needed pain medication compared with 52.7% in the HW group (P = 0.0378). Foreign body sensation was not different between the groups but there was significantly less impairment of physical activities (P = 0.0425) and seroma production (P = 0.0415) in the titanized ELW group compared to the HW group in the early postoperative period. CONCLUSION: Use of titanized ELW mesh for laparoscopic hernia repair did not affect the rate of chronic pain but it seems to improve early postoperative convalescence. Its use without any fixation can be recommended in TAPP for inguinal hernia patients with a defect size ≤3 cm.

Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials.

BACKGROUND: For the scientific evaluation of the endoscopic and open mesh techniques for the repair of inguinal hernia, meta-analyses of randomized controlled trials (RCT) are necessary. The Lichtenstein repair is one of the most common open mesh techniques and therefore of special interest. METHODS: After an extensive search of the literature and a quality assessment, a total of 34 RCT comparing endoscopic procedures both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP)--with various open mesh repairs were deemed to be suitable for a formal meta-analysis of the relevant parameters. These studies included data for 7,223 patients. Trials that used the Lichtenstein repair for the control group (23 of 34 trials) were analyzed-separately. RESULTS: Significant advantages for the endoscopic procedures compared with the Lichtenstein repair include a lower incidence of wound infection (Peto odds ratio, 0.39; 95% confidence interval, 0.26, 0.61), a reduction in hematoma formation (0.69 [0.54, 0.90]) and nerve injury (0.46 [0.35, 0.61]), an earlier return to normal activities or work (-1.35[-1.72, -0.97]), and fewer incidences of chronic pain syndrome (0.56[0.44, 0.70]). No difference was found in total morbidity or in the incidence of intestinal lesions, urinary bladder lesions, major vascular lesions, urinary retention and testicular problems. Significant advantages for the Lichtenstein repair include in a shorter operating time (5.45[1.18, 9.73]), a lower incidence of seroma formation (1.42[1.13, 1.79]), and fewer hernia recurrences (2.00[1.46, 2.74]). Similar results are seen when endoscopic procedures are compared with other open mesh repairs. However, in this comparison, total morbidity was lower with the endoscopic operations (0.73[0.61, 0.89]). The incidence of seroma formation, chronic pain syndromes, and hernia recurrence was not significantly different. CONCLUSION: Endoscopic repairs do have advantages interms of local complications and pain-associated parameters. For more detailed evaluation further well-structured trials with improved standardization of hernia type, operative technique, and surgeons' experience are necessary.

Comparison of endoscopic techniques vs Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials.

BACKGROUND: We performed a scientific evaluation of the efficacy of different surgical techniques for inginual hernia repair and supported our findings by conducting a systematic review of randomized studies comparing endoscopic with open nonmesh suture techniques. METHODS: After an extensive search of the literature, a total of 27 studies (41 publications) with evidence level lb were identified. These studies randomly compared endoscopic with open nonmesh suturing techniques. The quality of data sufficed to enable a quantitative meta-analysis of various parameters using the original software of the Cochrane Collaboration. Due to its superiority in comparison to other open nonmesh suturing techniques, the Shouldice repair technique was analyzed separately. RESULTS: The systematic comparison of endoscopic techniques with the Shouldice repair showed that these techniques had significant advantages in terms of the following parameters: total morbidity, hematoma, nerve injury, and pain-associated parameters such as time to return to work, and chronic groin pain. The Shouldice operation has the advantages of a shorter operating time and a lower incidence of wound seroma. There was no difference regarding the incidence of major complications, wound infection, testicular atrophy, or hernia recurrence. Open non-Shouldice suturing techniques are associated with higher recurrence rates and more wound infections than endoscopic operations. CONCLUSION: In comparison to open nonmesh suture repair techniques, endoscopic repair techniques have significant advantages in terms of pain-associated parameters. For the revaluation of long-term complications such as hernia recurrence and chronic groin pain, further clinical examination of the existing study collectives is needed.

Recurrence after endoscopic transperitoneal hernia repair (TAPP): causes, reparative techniques, and results of the reoperation.

BACKGROUND: Even though the introduction of endoscopic surgical techniques to inguinal hernia therapy dates back 10 years, only a few data exist concerning the problem of development of a recurrence after endoscopic repair. Similarly there are only anecdotal reports on the feasibility of an endoscopic reintervention for this situation. For the first time we are able to present data of a prospective study on both issues. STUDY DESIGN: We analyzed the data of a prospectively documented series of 46 transperitoneal hernia repair reinterventions after endoscopic hernia repair. In 33 patients from our own clinic we evaluated the cause of recurrence after transperitoneal hernia repair. Together with these and 13 more patients sent to us from external clinics we examined the efficiency of an endoscopic reoperation. RESULTS: When implanting a 13 x 8-cm mesh with an incision (phase I) we found the main cause of recurrence to be that the mesh was too small (47.4%) and the region of the mesh incision was insufficient (42.1%). After a change to a 15 x 10-cm implant without incision (phase II) the main cause of recurrence was found to be a mesh dislocation (38.9%) and the rate of recurrence dropped from 2.8% (phase I) to 0.36% (phase II). The transperitoneal reoperation lasted for a median of 75 minutes (range 45 to 170 minutes) for the medial recurrence and a median of 110 minutes (range 65 to 190 minutes) for the lateral recurrence (p = 0.009). The total rate of complications was 10.9%, and the rate of re-recurrence was 0% after a median followup of 26 months (range 2 to 72 months). CONCLUSIONS: To avoid hernia recurrence after transperitoneal hernia repair operations a sufficiently large mesh (at least 15 x 10 cm) has to be implanted, preferably without an incision, after an extensive parietalization. The endoscopic reoperation for recurrence can be done only in a transperitoneal way and is effective with comparably low complication rates. The procedure is significantly easier for a medial recurrence compared with a lateral recurrence. This method of reoperation should be reserved for endoscopically experienced surgeons.

A single institution's experience with transperitoneal laparoscopic hernia repair.

BACKGROUND: Previous evaluations of endoscopic hernia surgery mostly are based on small prospectively documented series or on a few randomized comparative studies. In the following, results of a large single-institution experience concerning the transabdominal preperitoneal patch (TAPP) technique with regard to the development of methods and the routine use are described. METHODS: From April 1993 to March 1997, 2,700 TAPP procedures were performed at the Department of General and Visceral Surgery, Marien-hospital, Stuttgart, Germany. The follow-up was documented prospectively in all cases by use of computed data base. RESULTS: The majority of patients (83.8%) were operated because of primary hernias. In 17.2% a first or multiple recurrence of an inguinal hernia was indicated. At a median postoperative observation period of presently 20 months and a follow-up rate of 86.5%, 28 recurrences have been determined so far (total recurrence rate 1.03%), 6 of which occurred after a recurrent hernia reparation (1.33%) and 22 after primary hernia repair (0.97%). The most common cause for recurrence was in 39.3% a mesh (12 x 8 cm) being too small. The total complication rate was 4.6%; as an expression of the learning curve it was reduced from 7.8% (operations 1 to 500) to 2.8% (operations 2,200 to 2,700). CONCLUSIONS: According to our experience, the TAPP technique is sufficiently applicable as a standard method for an unselected group of patients in a routine setting. It is especially suited to the repair of recurrent and bilateral hernias as well as for patients with a high risk for recurrence that can profit from a tension-free endoscopic procedure, particularly in case of obesity.

Simultaneous bilateral laparoscopic inguinal hernia repair: an analysis of 1336 consecutive cases at a single center.

BACKGROUND: We compare the use of unilateral and simultaneous bilateral laparoscopic hernioplasty [transabdominal preperitoneal patch (TAPP)] METHOD: We employed a prospective consecutive single-center trial lasting from April 1993 to December 2000. RESULTS: In our study, 5524 consecutive patients underwent 6860 laparoscopic hernia repairs. The median age in group A (unilateral repair, n = 4188) was 58 years (16-94 years), and that in group B (simultaneous bilateral repair, n = 1336) was 60 years (19-97 years) in (simultaneous bilateral repair, n = 1336). Morbidity in group A was 3.2% (135/4188) with a 0.6% reoperation rate (24/4188); in group B morbidity was 5.0% (67/1336) with a 1.4% reoperation rate. (19/1336). Morbidity and reoperation rates showed no statistically significant difference between the two groups in relation to number of repairs in group B. After a median 24-month clinical follow-up period (1-84 months) (follow-up rate 93.1%) 38 recurrences were observed in group A (0.9%) and 17 in group B (0.6%; 17/2672) (p = 0.2668). Median time off work was 14 days after unilateral (2-63 days) and 17 days after bilateral repair (3-100 days) (p = 0.1359). Pain levels (numerical analogue scale) and incidence of persistent inguinal and scrotal pain are not higher after bilateral repair. CONCLUSION: Compared to unilateral repair, bilateral simultaneous laparoscopic hernia repair (TAPP) is safe, comfortable for patients, and cost-effective, without increased morbidity or recurrence risk. Bilateral inguinal hernia is an ideal indication for endoscopic transabdominal repair.

Scrotal hernias: a contraindication for an endoscopic procedure? Results of a single-institution experience in transabdominal preperitoneal repair.

INTRODUCTION: Endoscopic repair was introduced for use with inguinal hernia therapy more than 10 years ago. The technique as well as the indications for this method are debated, however. As a borderline inguinal hernia situation, the scrotal hernia in particular evokes vehement objections to an endoscopic procedure because of the anticipated problems and complications in dissecting the extended hernia sac. The efficiency of the laparoscopic transabdominal preperitoneal (TAPP) technique in the treatment of scrotal hernia therefore is discussed in this article. METHODS: Laparoscopic hernia repair (TAPP) has been performed in our department since 1993. Data are collected by a prospective documentation of operative and follow-up results. For evaluation, a comparison of scrotal and normal hernia repair was performed. RESULTS: Between April 1993 and June 1998 the TAPP technique was used to treat 191 scrotal hernias, 42 (22%) of which were recurrent hernias. The median operating time for a normal inguinal hernia repair was 45 min, whereas scrotal hernias required a median of 65 min and irreducible scrotral hernias a median of 68.5 min. Major complications were observed in 1.6% of scrotal and 0.6% of normal inguinal hernia repairs. The most frequent scrotal hernia repair problem was the formation of a seroma, 10.5% of which had to be evacuated. During a follow-up period of 30 months, we found a total of two recurrences (1.05%). CONCLUSION: In scrotal hernia repair, TAPP is not associated with higher complication rates and can be performed with efficiency comparable with that in normal inguinal hernia repair.

Laparoscopic transperitoneal hernia repair of incarcerated hernias: Is it feasible? Results of a prospective study.

BACKGROUND: Laparoscopic transperitoneal hernia repair (TAPP) has proved its efficiency in elective surgery. However, TAPP results with incarcerated hernias still are unknown. METHODS: Data from a prospective study were evaluated with regard to TAPP repair for both chronically and acutely incarcerated hernias. RESULTS: During a 6-year period, 220 incarcerated hernias were repaired (194 via TAPP). The median operation time for TAPP was 55 min. An accompanying resection therapy became necessary for only four of the emergency cases (11.1%) and two of the chronically incarcerated cases (1.3%) in the TAPP group. Postoperative morbidity was 2.8% in the emergency group and 3.8% in the chronically incarcerated group, which does not differ from the rate for TAPP used on reducible hernias. One recurrence was found 26 months after TAPP reconstruction (0.5%). CONCLUSION: Laparoscopic inguinal hernia repair (TAPP) represents an efficient therapeutic concept in the treatment of both chronically and acutely incarcerated inguinal hernias.

Insufflation profile and body position influence portal venous blood flow during pneumoperitoneum.

BACKGROUND: We investigated changes in portal venous blood flow (PVBF) during carbon dioxide (CO2) pneumoperitoneum to evaluate the effects of different insufflation profiles and body positions. METHODS: An established rat model was extended by implanting a portal vein flow probe that would enable us to measure PVBF for 60 min [t0-t60] in animals subjected to a CO2 pneumoperitoneum with an intraabdominal pressure (IAP) of 9 mmHg. Forty-eight male Sprague-Dawley rats were randomized into the following four experimental and two control groups: decompression group D1 ( n = 8), desufflation for 1 min every 14 min; decompression group D2 ( n = 8), desufflation for 5 min, after 27 min; position group P1 ( n = 8), 35 degrees head-up position; position group P2 ( n = 8), 35 degrees head-down position; negative control group C1 ( n = 8), no insufflation; positive control group C2 ( n = 8), constant IAP of 9 mmHg for 60 min. RESULTS: Pneumoperitoneum and body positions, respectively, reduced PVBF [t1-t60] significantly ( p < 0.001) by 32.0% C2, 32.8% D1, 31.1% D2, 40.8% P1, and 48.5% P2, as compared to PVBF at t0 in each group. There was a significant difference in PVBF reduction between P1 and P2 and also between C2 and both P1 and P2 ( p < 0.04). CONCLUSIONS: CO2 pneumoperitoneum reduces PVBF significantly (>30%). Extreme body positions (35 degrees tilt) significantly intensify PVBF reduction. PVBF reduction is significantly more dramatic in subjects placed in a 35 degrees head-down position. Short desufflation periods did not improve mean PVBF, but it may have beneficial immunological and oncological effects that warrant further investigation.

Laparoscopic surgery complications associated with trocar tip design: review of literature and own results.

In the last 10 years, there has not been an abdominal surgical procedure that has not been performed by laparoscopic means. The enthusiasm of surgeons active in this field often neglects problems, especially with basic instruments which are important vehicles for the laparoscopic technique. The purpose of this study was to focus on trocar-related problems with special respect to the tip design. On the basis of a prospective study of laparoscopic transperitoneal hernia repair (TAPP) and laparoscopic Nissen fundoplication, we evaluated our data concerning trocar-related complications at the abdominal wall. We compared two groups of patients treated in a nonrandomized design with either sharp cutting single-use trocars or cone-shaped non-cutting reuseable trocars. The evaluation of our own data showed an incisional hernia in 1.83% of patients treated with a sharp trocar tip, a complication which could be significantly lowered, to 0.17%, with a conic tip design. Similar results could be seen with trocar-related bleeding events at the insertion site in the abdominal wall. In most publications, trocar design and related complications are unmentioned. Our data demonstrate a reasonable benefit for a conic tip design, which enables atraumatic insertion through the abdominal wall. The reuseable steel version furthermore holds a considerable cost-saving potential.

[Surgical therapy of colonic diverticulitis--how reliable is primary anastomosis?]. / Chirurgische Therapie der Colondiverticulitis--Wie sicher ist die primäre Anastomose?

INTRODUCTION: The aim of the study was to evaluate the modern principles of surgery in diverticulitis, e.g. early elective resection and primary anastomosis. METHODS: The data of 445 consecutive patients were retrospectively analysed after classifying all cases in four subgroups according to a modified Hinchey classification (stages 0-III). RESULTS: Within our study group the morbidity was 26.5% (n = 118) and the mortality was 1.6% (n = 7). In 96% (n = 425) of all cases and in 64% (21/33) of patients with perforated diverticulitis and peritonitis (stage III), a primary anastomosis was performed. Four patients of the study group showed insufficient anastomosis (0.9%). No leakage was observed from any of the anastomoses performed in stage III diverticulitis. Stage of inflammation and age of patient correlate with morbidity and mortality. Some 53% (94/177) of the patients in stage II and 67% (22/33) of the patients in stage III had never showed symptoms of diverticulitis before. CONCLUSION: Prophylactic surgery to avoid life-threatening situations, including abscess formation or perforation, is not possible in many cases. However, especially patients at risk (age, coexisting illness) should undergo early surgery. Primary anastomosis can be performed safely even at an advanced stage.

[Risks and benefits of laparoscopic hernia-plasty (TAPP). 5 years experiences with 3,400 hernia repairs]. / Risiko und Nutzen der laparoskopischen Hernioplastik (TAPP). 5 Jahre Erfahrungen bei 3400 Hernienreparationen.

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 hernia therapy (TAPP) as a teaching operation]. / Laparoskopische Leistenhernientherapie (TAPP) als Ausbildungsoperation.

INTRODUCTION: Because of an increasing number of endoscopic hernia procedures, it is important to look into the possibility of standardizing these techniques helping surgeons to acquire the operative skills necessary. MATERIAL AND METHODS: To discuss these aspects, the documented data on TAPP operations that have been carried out in this department since 1993 were analyzed. The results of teaching procedures were compared with those of experts after they had gotten past the learning and development curve. RESULTS: A total of 778 teaching procedures were performed by 10 surgeons with an individual experience of 30.5 operations (median). Before starting the first procedure, 89 were done by assistants operating the camera. The morbidity of teaching operations was 1.9% compared to 1.4% for those performed by experts. After a median follow-up of 23 months there were two recurrences (0.23%) in the expert group and none in the teaching group (follow-up 16 months). CONCLUSION: Because of the potentials of standardization of the TAPP technique, the results of teaching were equal to expert operations. Therefore, TAPP is suitable for application in a routine setting.

[Follow-up results of laparoscopic cholecystectomy]. / Spätergebnisse nach laparoskopischer Cholecystektomie.

Following a laparoscopic cholecystectomy 400 patients have been interviewed with a questionnaire on the late results of the surgery (15 to 40 months postop.). The cholecystectomies had been performed within the time from March 7, 1990 to April 30, 1992 in Tübingen. After a mean of 16.8 days the patients returned to work, while they themselves felt reduced for an average of 10.6 days. 11.9% of the patients complained of slight wound healing problems and in 3.1% wound infections have been registered. Although 97% of the patients were satisfied with the results of surgery, 8.7% still complained of upper abdominal trouble. Slight persistent problems like light pain or flatulence have been reported by 19%.

Investigation on radiofrequency and laser (980 nm) effects after endoluminal treatment of saphenous vein insufficiency in an ex-vivo model.

OBJECTIVES: An ex-vivo model for the experimental evaluation of endoluminal thermal procedures for occlusion of saphenous veins was developed. Radiofrequency obliteration (RFO) and endovenous laser therapy (ELT) were compared using this model. DESIGN: Experimental ex-vivo treatment study. MATERIALS AND METHODS: The model consists of the subcutaneous foot veins from freshly slaughtered cows which were reperfused in situ with heparinised bovine blood. The veins were treated with either radiofrequency (RFO n=5) or with endoluminal 980 nm laser light (ELT n=5) using a continuous pull-back for RFO and a stepwise illumination and pull-back protocol for ELT. Immediately after treatment perivenous tissue and veins were examined macroscopically. In a second study the same treatment parameters were used in four further vein segments with RFO (n=2) and ELT (n=2). These vein segments were examined microscopically in HE-stained histological sections. RESULTS: Induration of the vessel wall and contraction of the vessel lumen were observed after RFO. Laser treatment produced carbonised lesions of the vein wall. After 12-24 laser exposures these lesions often became transmural, causing complete perforation of the vessel wall. Histological evaluation after radiofrequency treatment demonstrated homogenous circular thermal tissue alteration with disintegration of intima and media structures. Histological evaluation after endovenous laser treatment showed large variations of thermal tissue effects. Tissue effects ranged from major tissue ablation and vessel wall disruption to minor effects located between laser exposures and on the opposite vessel wall. CONCLUSIONS: Our model is suitable for systematic scientific evaluation of endovenous thermal occlusion procedures. Our first results and theoretical considerations indicate that endovenous laser treatment should be modified in order to ensure controlled homogenous circular thermal damage, avoiding vessel wall perforation and damage to perivascular structures.

Endoscopic inguinal hernia repair in comparison with Shouldice and Lichtenstein repair. A systematic review of randomized trials.

AIMS: This article provides an overview of randomized studies which compare endoscopic hernia repair techniques (TAPP/TEP) with the Shouldice and Lichtenstein repair. METHODS: Systematic analysis of 33 published studies which meet the criteria of a randomized controlled trial with a high evidence level. RESULTS: The majority of the studies document statistically significant advantages of the endoscopic repair techniques in relation to wound pain (15/22), need for analgesics (16/21), return-to-work time (16/22) and physical activity (18/25), although only one study showed significant advantages of the Lichtenstein method. Six of 28 studies showed a lower morbidity in comparison to open approaches, although 22 of 28 studies documented no significant difference. The first long-term studies with follow-up periods between 5 and 6 years also show advantages of the endoscopic techniques. CONCLUSION: Even with cautious interpretation of the data, it is clear that endoscopic techniques are more comfortable for patients and that morbidity is no higher than for open procedures. Due to the short follow-up periods final evaluation regarding long-term complications and recurrence is not yet possible.

Long-term results of a randomized clinical trial between laparoscopic hernioplasty and shouldice repair.

BACKGROUND: At present only short-term follow-up data are available to compare endoscopic and conventional hernia surgery. This paper presents data from a randomized study 6 years after initial recruitment. METHODS: In 1993 a randomized comparative study of transabdominal preperitoneal (TAPP) and Shouldice repair was commenced. Endpoints were rate of recurrence, late complications, complaints and patient satisfaction. RESULTS: The rate of recurrence in the TAPP group was one (2 per cent) of 48 patients and in the Shouldice group two (5 per cent) of 43. Only five patients in the Shouldice and three in the TAPP group reported slight discomfort in the inguinal region at 6-year follow-up. In neither group was chronic pain syndrome observed. Altogether, 46 (96 per cent) of 48 patients in the TAPP group and 35 (81 per cent) of 43 of those having the Shouldice procedure stated complete satisfaction with the hernia repair. CONCLUSION: Long-term evaluation demonstrated greater satisfaction with the result of the repair in the endoscopic group. The difference between the groups in the recurrence rate was not significant, because of the small numbers. The TAPP method appears to be an effective surgical alternative in patients with inguinal hernia.