A study to improve identification of the retroperitoneal course of iliohypogastric, ilioinguinal, femorocutaneous and genitofemoral nerves during laparoscopic triple neurectomy.

BACKGROUND: Laparoscopic triple neurectomy is an available treatment option for chronic groin pain, but a poor working knowledge of the retroperitoneal neuroanatomy makes it an unsafe technique. OBJECT: Describe the retroperitoneal course of iliohypogastric, ilioinguinal, lateral femoral cutaneous and genitofemoral nerves, to guide the surgeon who operates in this region. METHODS: Fifty adult cadavers were dissected resulting in 100 anatomic specimens. Additionally, 30 patients were operated for refractory chronic inguinal pain, using laparoscopic triple neurectomy. All operations and dissections were photographed. Measurements were made between the nerves of the lumbar plexus and various landmarks: interneural distances in a vertical midline plane, posterior or anterior iliac spine and branch presentation model. RESULTS: The ilioinguinal and iliohypogastric nerves were independent in 78% (Type II) and separated by an average of 2.5 ± 0.8 cm. In surgery study, only 38% were recognized as Type II and at a significantly greater distance (3.5 ± 1.2 cm, p < 0.001). The distance between ilioinguinal and lateral femoral cutaneous nerves was also greater during surgery, with statistical significance (5.1 ± 1.5 versus 4.2 ± 1.5, p < 0.005). The distance of the nerves to their bone references were not statistically different. The genitofemoral nerve emerged from the psoas major muscle in 20% as two separate branches (Type II), regardless of the study. The lateral femoral cutaneous nerve had a mean distance of 0.98 ± 1.6 cm medial to the anterior superior iliac spine. CONCLUSION: The identification of the IH, II, FC and GF nerves is essential to reduce the rate of failures in the treatment of CGP. The frequent anatomical variations of the lumbar plexus nerves make knowledge of their courses in the retroperitoneal space essential to ensure safe surgery. The location of the nerves in the LTN is distorted by up to 1 cm. regarding references in the cadavers.

Does Abdominoplasty Add Morbidity to Incisional Hernia Repair? A Randomized Controlled Trial.

Background Abdominoplasty is considered an operation linked to a considerable rate of morbidity. The convenience of simultaneously performing an incisional hernia repair and an abdominoplasty remains controversial. Methods A total of 111 patients were randomized prospectively to compare isolated incisional hernia repair and hernia repair when combined with abdominoplasty. Primary end points were in-hospital stay and early morbidity. Secondary end points were late morbidity, recurrences, and quality of life. Patients were followed-up for 24 months. Results Duration of the surgical procedure differed significantly between both groups (39 vs 85 minutes, P < .001) and postoperative hospital stay (2.5 vs 3.5 days; P < .001). No statistically significant differences in early or late morbidity between both groups were detected. The perceived quality of life for patients was higher in the combined surgery group (P < .001) that in the isolated hernia repair group. Conclusions Postoperative in-hospital stay and early and late morbidity do not differ significantly between isolated incisional hernia repair and simultaneous hernia repair with abdominoplasty, but associated abdominoplasty provides a higher quality of life when indicated.

Which should be the gold standard laparoscopic technique for handling Spigelian hernias?

BACKGROUND: The advantages and disadvantages of both extraperitoneal and intra-abdominal laparoscopic Spigelian hernia repair are still being discussed. To our knowledge, no study has compared both techniques in terms of safety, feasibility, and cost-effectiveness. METHOD: Prospective data were collected to compare the results of the extraperitoneal approach with the intra-abdominal approach in laparoscopic Spigelian hernia repair, between 2000 and 2012 (n = 16). Diagnosis was confirmed preoperatively by ultrasonography and/or tomography. RESULTS: Spigelian hernias occur mostly in women (69 %), on the left side (56 %) and at a median age of 62 (range: 38-83). In our study, the extraperitoneal technique was performed in seven patients, while the intra-abdominal approach was indicated in nine. No complications, re-admissions, or recurrences were detected in either during a mean follow-up of 48 months (range: 18 months-9 years). The statistical study showed that there was no difference in either morbidity or the recurrence rate between a totally extraperitoneal (TEP) and an intraperitoneal onlay mesh (IPOM) repair. The mean duration of an IPOM repair was, though, shorter than that of a TEP repair (30 vs. 48 min, P = 0.06). The combined fixation technique (tacks + glue) did not modify the results but did reduce the costs, as shown in the cost-effectiveness study where the intra-abdominal approach was cheaper (1260 vs. 2200 euros, P < 0.001). CONCLUSION: Laparoscopy seems to be a safe and feasible technique whichever the approach chosen, be it intra or extraperitoneal. Our experience shows that intra-abdominal laparoscopic Spigelian hernia repair should be recommended as the gold standard because of its technical and economic advantages. The IPOM procedure with a lightweight titanium-coated mesh fixed using a combined technique is a highly effective option for Spigelian hernia repair.

Is it possible to eliminate sutures in open (Lichtenstein technique) and laparoscopic (totally extraperitoneal endoscopic) inguinal hernia repair? A randomized controlled trial with tissue adhesive (n-hexyl-α-cyanoacrylate).

BACKGROUND: The morbidity linked to the use of sutures in inguinal hernioplasty is well known. Tissue adhesives may be an alternative, so as to be able to improve levels of postoperative comfort, but clinical experience using them is limited. The aim of this study is to evaluate the efficiency of cyanoacrylate as a substitute for sutures in the treatment of inguinal hernias. PATIENTS: Randomized clinical trial in abdominal wall unit. A total of 208 patients were operated upon for inguinal hernias of which 102 were unilateral hernias via open surgery using the Lichtenstein technique, randomized to receive prolene sutures (n = 52) or n-hexyl-α-cyanoacrylate glue (n = 50) and 106 were patients with bilateral inguinal hernias operated upon via totally extraperitoneal laparoscopy and randomized to receive either tackers (n = 54) or glue (n = 52). MAIN OUTCOME MEASURES: The primary endpoints were pain and recurrence. Secondary endpoints were operating time, postoperative morbidity, pain, and analgesic consumption. RESULTS: No morbidity associated with the use of the glue existed. The use of glue significantly reduced the mean of surgical time (12 minutes in open surgery, 13 minutes in laparoscopic surgery), pain, and analgesics consumption, both via the open and laparoscopic approaches (P < .001). After 1 year the adhesive did not change the recurrence rate in either of the approaches. The economic analysis shows potential yearly savings of 123 916.3 Euros. CONCLUSIONS: Substituting sutures with glue (n-hexyl-α-cyanoacrylate) in open or laparoscopic inguinal hernioplasty is safe with less postoperative pain and the same possibilities of recurrence.

Randomized clinical trial of laparoscopic hernia repair comparing titanium-coated lightweight mesh and medium-weight composite mesh.

BACKGROUND: The use of lightweight meshes in incisional hernia repair could have beneficial effects on quality of life. This study aimed to compare a new titanium-coated lightweight mesh with a standard composite mesh after laparoscopic incisional hernia repair. METHODS: A randomized controlled single-center clinical trial was designed using the basic principle of one unit, one surgeon, one technique (midline incisional hernia with a laparoscopic approach), and two meshes: a lightweight titanium-coated mesh (group 1) and a medium-weight collagen-polyester composite mesh (group 2) used in 102 patients. The primary end points were pain and recurrence. The secondary end points were morbidity and patient outcomes (analgesic consumption, return to everyday activities). RESULTS: The postoperative complication rates were similar for the two meshes. Pain was significantly less common in group 1 than in group 2 at 1 month (P = 0.029) but was similar for the two groups at 6 months and 1 year. There was a significant difference between the two groups in the average use of analgesics: 6.1 days in group 1 versus 1.6 days in group 2 (P < 0.001). The lightweight group returned to everyday activities after 6.9 days versus 9.7 days for the composite group (P < 0.001). The rate of recurrence did not differ between the two groups at the 2-year follow-up evaluation. CONCLUSIONS: The light titanium-covered polypropylene mesh was associated with less postoperative pain in the short term, lower analgesic consumption, and a quicker return to everyday activities than the Parietex composite medium-weight mesh. The recurrence rates at 2 years showed no difference between the two groups.

Surgical options in lumbar hernia: laparoscopic versus open repair. A long-term prospective study.

OBJECTIVE: To determine the safety and effectiveness of laparoscopic lumbar hernia repair. DESIGN: Prospective clinical study. SETTING: Abdominal wall unit, university hospital. PATIENTS: Between January 1995 and December 2008, data from 55 consecutive patients who had undergone laparoscopic (n = 35) or open (n = 20) lumbar hernia repair. MAIN OUTCOME MEASURES: The primary endpoint was recurrence; secondary endpoints were patient outcomes (morbidity, pain, and return to normal activity). RESULTS: Mean operating time (P = .01), hospital stay, return to normal activity, analgesic consumption, and pain at 1 month (P < .001) were significantly less in the laparoscopic group. Complications were similar in the 2 groups (37% vs 40%, respectively; P = .50). Traumatic hernias increased local complications versus incisional lumbar hernias (71.4% vs 29%; P = .007). Consumption of analgesics (6.8 ± 6.5 vs 18.1 ± 9.1; P < .001) and pain during the first month (no pain: 90% vs 54.3%; P = .015) were significantly less with a lightweight versus medium-weight mesh. The risk factors associated with recurrences development were localization (P = .01) and size (P = .008). Recurrence rates were 2.9% in the laparoscopic group and 15% in the open group (P = .13). CONCLUSIONS: Outcomes did not differ with respect to morbidity and recurrence rate after long-term follow-up; however, this study suggested that laparoscopic approach for lumbar hernia is safe, effective, and more efficient than open repair and can be considered the procedure of choice. Open surgery may be considered the best option in the diffuse hernias with size larger than 15 cm.

[Is sutureless hernia repair a safe option for treating abdominal wall hernias? A prospective study with a synthetic tissue adhesive (n-hexyl-alpha-cyanoacrylate)]. / ¿Es segura la hernioplastia sin sutura como opción para tratar las hernias de pared abdominal? Estudio prospectivo con un adhesivo tisular sintético (n-hexil-α-cianoacrilato).

INTRODUCTION: The use of tissue adhesives can be an alternative to suture fixation of the mesh, but experience in their use is very limited. MATERIAL AND METHODS: A prospective descriptive study was conducted on a group of 35 patients with inguinal hernias repaired by sutureless hernioplasty (20 by open and 15 by endoscopic), the prosthesis was fixed with a synthetic adhesive (n-hexyl-α-cyanoacrylate). This group was compared with another 35 patients for hernia repair with fixation sutures. All patients were scheduled for outpatient surgery. Peri-operative variables were recorded. The patients were followed up at one week, one month, 6 months and one year after surgery. RESULTS: There was no morbidity associated with the use of tissue adhesive (bruising, infection or skin necrosis). During a median follow-up of 15 months, no complications or recurrences were detected. In the open hernioplasty using adhesive significantly reduced surgery time (30 min versus 70 min, P=.001), postoperative pain (from 2.4 to 4.5 at one week, P<.001) and analgesic consumption (7 to 14 days, P<.001). In the laparoscopic approach are demonstrated significant differences in favour of the adhesive in pain (P=.001 at 24h), and in analgesic use (P<.001) was observed using the laparoscopic approach. The adhesive did not alter the morbidity or the relapse rate at one year in any of the two approaches, and the financial analysis showed an annual savings of 117,461.2 euros (about 460 hernias). CONCLUSION: The use of a synthetic tissue adhesive (n-hexyl-α-cyanoacrylate) is safe as a means of fixation in uncomplicated hernia and patients without comorbidity, and with good postoperative results.

Management of non-midline incisional hernia by the laparoscopic approach: results of a long-term follow-up prospective study.

BACKGROUND: The role of the laparoscopic approach in the repair of non-midline incisional hernias is controversial due to the absence of adequate scientific studies. This study aimed to determine the safety and efficacy of laparoscopic repair for non-midline incisional hernias. METHODS: This prospective clinical study was conducted in an abdominal wall unit of a teaching hospital. Patients underwent surgery for non-midline incisional hernias using the laparoscopic approach (n = 73) and were classified into three groups: subcostal, iliac, and lumbar. The primary end point was recurrence. The secondary end points were intraoperative parameters, comorbidity, and patient outcomes. The median follow-up period was 62 months (range, 36-170 months). RESULTS: No hospital stay was needed for 34% of the patients. The remaining patients needed an average hospital stay of 2.7 days. The most frequent morbidity was hematoma. The overall recurrence rate was 8.2% and was higher for the subcostal hernias (25%). The three groups differed in size, local morbidity, and recurrence (P < 0.05). The independent risk factors for recurrence were size (hazard ratio [HR], 2.16; 95% confidence interval [CI], 1.08-4.33) and local morbidity (HR 30.62; 95% CI 1.22-768-82). The best predictor of recurrence was a hernia diameter greater than 15 cm. The only predictive factor of local morbidity was obesity (P < 0.007). CONCLUSIONS: The laparoscopic approach is a safe and effective treatment for non-midline incisional hernias. Caution should be taken with subcostal hernias, obese patients, and a defect size greater than 15 cm. An algorithm is suggested to guide the "rational" treatment of non-midline incisional hernias.

Reduction in inappropriate hospital use based on analysis of the causes.

BACKGROUND: To reduce inappropriate admissions and stays with the application of an improvement cycle in patients admitted to a University Hospital. The secondary objective is to analyze the hospital cost saved by reducing inadequacy after the implementation of measures proposed by the group for improvement. METHODS: Pre- and post-analysis of a sample of clinical histories studied retrospectively, in which the Appropriateness Evaluation Protocol (AEP) was applied to a representative hospital sample of 1350 clinical histories in two phases. In the first phase the AEP was applied retrospectively to 725 admissions and 1350 stays. The factors associated with inappropriateness were analysed together with the causes, and specific measures were implemented in a bid to reduce inappropriateness. In the second phase the AEP was reapplied to a similar group of clinical histories and the results of the two groups were compared. The cost of inappropriate stays was calculated by cost accounting. SETTING: General University Hospital with 426 beds serving a population of 320,000 inhabitants in the centre of Murcia, a city in south-eastern Spain. RESULTS: Inappropriate admissions were reduced significantly: 7.4% in the control group and 3.2% in the intervention group. Likewise, inappropriate stays decreased significantly from 24.6% to 10.4%. The cost of inappropriateness in the study sample fell from 147,044 euros to 66,642 euros. The causes of inappropriateness for which corrective measures were adopted were those that showed the most significant decrease. CONCLUSIONS: It is possible to reduce inadequacy by applying measures based on prior analysis of the situation in each hospital.

Long-term results of laparoscopic repair of incisional hernias using an intraperitoneal composite mesh.

BACKGROUND: This study was designed to evaluate the long-term complications and recurrences of laparoscopic repair of incisional hernias. Very few studies evaluate objectively the long-term results of laparoscopic incisional hernia repair. METHODS: Data for 200 consecutive patients who underwent laparoscopic incisional hernia repair (LIHR) in a university teaching hospital using a standardized procedure between January 1994 and December 2006 were collected prospectively. The median follow-up was 6 (range, 1-12) years. RESULTS: The conversion rate from laparoscopic to open approach was 2.5% (205 initial patients). Mean operative time was 51 minutes; 63% of these patients were discharged the day of surgery. Mean hospital stay was 2.6 days. There was an overall postoperative complication rate of 15%. We had four small bowel injuries repaired laparoscopically, and one patient died as a result of a sepsis. Postoperative pain was limited, with a mean analgesics requirement of 6.8 (range, 0-30) days. During a mean follow-up of 60 (range, 12-144) months, the recurrence rate was 6.2%, which developed within 1 year of the operation and associated with body mass index >37, defect size >10 cm, and multiple Swiss-cheese defects (p < 0.01). CONCLUSIONS: 1) Intra-abdominal composite mesh is good tolerance. 2) The recurrence rate is low and within 1 year of the operation. 3) The long-term morbidity with LIHR is moderate. 4) The risk of intestinal injury is not predictable. 5) Reoperations can be performed with sufficient guarantee using laparoscopy.

[Historic analysis of complex incisional hernia: to an understanding of the double prosthetic repair technique]. / Análisis histórico del tratamiento de la hernia incisional compleja: hacia una comprensión de la técnica de doble reparación protésica.

The treatment of complex incisional hernias is, on occasions, a real social and professional, and still controversial, challenge. A multitude of techniques have been described over the years in an attempt to solve this problem. The social context and technological development of each period are essential to understand the continuous changes in the way of performing these techniques. This article caries out an historical review of the prosthetic treatment of incisional hernias, trying to understand and apply the basic principles of the treatment of all incisional hernias to the repair with a double mesh.

Laparoscopic incisional hernia repair as a day surgery procedure: audit of 127 consecutive cases in a university hospital.

BACKGROUND: Findings have shown that laparoscopic incisional hernia repair is superior to conventional open techniques. The objective of the current study was to evaluate the results of laparoscopic surgery on incisional hernias in an outpatient surgery unit in a university hospital. METHODS: Data were gathered prospectively for all laparoscopic incisional hernia repairs from January 1997 to December 2006. A total of 127 patients were operated in an outpatient surgery unit. The patients' clinical features, hernia type, intraoperative and postoperative complications, and reasons for hospital admission are studied. RESULTS: None of the patients required readmission to hospital, 15 had no need for analgesic treatment (11.8%) and the mean requirement was 6 days. The mean time of return to normal activity was less than 10 days and all the patients expressed their satisfaction with the procedure they received. During follow-up we detected 5 recurrences (4.4%). The statistical study showed no significant differences between the hospitalized patients and those treated on an ambulatory basis with regard to morbidity and recurrence rate (P<0.05). We do find a lower intraoperative and early postoperative (<30 d) complication rate in favor of the ambulatory patients (P<0.001). CONCLUSIONS: Laparoscopic repair of incisional hernias can be performed as a highly efficient ambulatory procedure with igual morbidity and recurrences than hospitalized patients.

Controversies in the current management of lumbar hernias.

BACKGROUND: Abdominal wall surgery has changed dramatically in recent years. The current management of lumbar hernias should reflect the development of modern imaging techniques and new forms of noninvasive treatment. OBJECTIVE: To review and update knowledge on lumbar hernias. DATA SOURCES: Literature review using MEDLINE with the key words "lumbar hernia" for the years 1950 through 2004. For an analysis prior to this date (1750-1950), we used cases reported by Thorek. Our own study of 28 patients was also included. STUDY SELECTION: All articles reporting clinical cases on lumbar hernia. DATA EXTRACTION: Two reviewers analyzed the epidemiological, clinical, and treatment data of the articles. DATA SYNTHESIS: One hundred thirty-five clinical case articles and 8 studies with more than 5 patients, together with our personal experience of 28 cases, were analyzed. Nine percent of acquired lumbar hernia cases presented for emergency surgery, which means that a clinical diagnosis was completed with computed tomography in more than 90% of the cases. None of the published classifications has a therapeutic orientation. We present an original classification based on 6 categories and 4 types. In our study, there was a predominance of incisional hernias (79%), with no difference with regard to sex or location but with a predominance in the upper space (47%). Laparoscopic treatment accounts for 9% of the publications' cases and there is only 1 prospective comparative study. CONCLUSIONS: The use of a complete classification and tomography must be standard practice in the preoperative protocol of patients with lumbar hernia. The laparoscopic approach seems to be the best option for treating small or moderate defects; open surgery can be reserved for large defects and to salvage failures with the laparoscopic approach.

Laparoscopic hernioplasty in secondary lumbar hernias.

BACKGROUND: Lumbar hernia is an uncommon defect of the posterior abdominal wall, and surgical treatment is still controversial. The aim of this study was to analyze the utility of the laparoscopic approach in the repair of these hernias. MATERIALS AND METHODS: We undertook a descriptive analysis of 15 patients diagnosed with lumbar hernia who underwent surgery with transabdominal laparoscopy between 1997 and 2004. The following variables were analyzed: clinical data, intraoperative and postoperative complications, operative time, length of hospital stay, analgesic consumption, and recurrences. The technique was evaluated aesthetically by measuring the abdominal perimeter using a tape measure. The mean follow-up was 32 months (range, 12-55 months). RESULTS: Intraoperative morbidity consisted of two cases of bleeding caused by the mechanical suture. Postoperative morbidity consisted of 3 cases of hematomas, 2 of seromas, and 2 of transitory pain. Seven patients (47%) were treated as day cases, and only one required admission due to pain. At 12-month follow-up we found one recurrence and a significant reduction in abdominal perimeter (P < 0.05). CONCLUSION: The transabdominal laparoscopic approach offers good clinical and aesthetic results both for the patient and the hospital, as almost half of the cases can be treated as day cases. We believe it should be considered the technique of choice for incisional lumbar hernia repair.

Obturator hernia as a cause of chronic pain after inguinal hernioplasty: elective management using tomography and ambulatory total extraperitoneal laparoscopy.

Obturator hernia is a rare variety of pelvic hernia. Preoperative diagnosis is still uncommon and influences treatment and prognosis. Clinical suspicion and tomography are fundamental for establishing a preoperative diagnosis. Subsequently, elective treatment via the total extraperitoneal laparoscopic approach seems to offer the best results for both the patient and the hospital. This management might reduce the high rates of associated morbidity and mortality. We present the case of a patient with chronic pelvic pain after hernia surgery in whom tomography confirmed the existence of a bilateral obturator hernia. Details are given of diagnostic and therapeutic management using ambulatory total extraperitoneal laparoscopy. We recommend ruling out obturator hernia as a possible cause of chronic pain after hernia repair.