Technical tips following more than 2000 transabdominal preperitoneal (TAPP) repair of the groin hernia.

BACKGROUND: Laparoscopic approach is increasingly adopted as a preferred method to treat inguinal hernia. Transabdominal preperitoneal and total extraperitoneal repairs are the 2 techniques currently used. METHODS: Between September 1999 and July 2009, more than 2000 patients underwent transabdominal preperitoneal repair of groin hernia at our minimal access unit. A standard technique is used in the majority of patients. Modifications are applied when necessary depending on the complexity of the case. All patients are considered for laparoscopic repair unless they have large irreducible inguino-scrotal hernia or are considered high risk for pneumoperitoneum because of their cardiorespiratory problems. Day surgery, 23-hour service, and inpatient admission are adopted depending on the age, body mass index, comorbidities, and social support. Outpatient postoperative follow-up is normally arranged for 1 visit. RESULTS: A total of 2196 patients underwent transabdominal preperitoneal groin hernia repair. Morbidity included 63 (2.86%) seromas. Hematoma is reported in 6 (0.27%), 2 (0.09%) patients needed blood transfusion whereas 1 patient needed reexploration. Pain and parasthesia at 6 months are reported in 6 (0.27%) and 2 (0.09%) patients, respectively. Port-site hernia is confirmed in 5 (0.22%) patients, whereas in 2 (0.09%) mesh infections are reported. Both were treated successfully using intravenous antibiotics. Four (0.1%) hydroceles are confirmed and 1 (0.04%) bowel obstruction through a defect in the peritoneal flap. Recurrence of hernia is confirmed in 4 (0.18%) patients. CONCLUSIONS: A standardized technique of laparoscopic hernia repair is associated with minimum morbidity. Modification of the technique is necessary in some patients depending on the complexity of the case.

A modified approach to laparoscopic antireflux surgery may decrease postoperative dysphagia and gas bloat syndrome.

BACKGROUND: Laparoscopic antireflux surgery has passed the test of time to prove its efficacy and advantage over the traditional approach. Several modifications of the original Nissen fundoplication have been introduced and practiced by surgeons with variable outcomes. METHODS: This modified technique of laparoscopic fundoplication, which we use, is basically a spiral wrap. It is constructed by using several specifically located Ethibond stitches to keep the gastroesophageal junction and a length of the esophagus inside the abdomen without esophageal stitching. Postoperative outcome including patient satisfaction was assessed clinically during follow-up visits. Patients with recurrent symptoms and complications were assessed by appropriate tests. All patients were seen at 6 weeks, 6 months, 12 months, and annually after the operation. RESULTS: Fifty-seven patients underwent laparoscopic antireflux surgery using the spiral wrap technique. Four patients reported occasional heartburn and only 1 patient developed regurgitation after 1 year from the operation. Nine patients developed early dysphagia and 2 patients had gas bloat syndrome at 6 weeks postoperative assessment. No dysphagia or gas bloat syndrome was confirmed after a year and no revisional surgery was reported. CONCLUSIONS: Modification of the classic fundoplication to spiral wrap is associated with acceptable morbidity and low incidence of postoperative dysphagia and gas bloat syndrome.

Long-term study of port-site incisional hernia after laparoscopic procedures.

BACKGROUND: Laparoscopic surgery is widely practiced and offers realistic benefits over conventional surgery. There is considerable variation in results between surgeons, concerning port-site complications. The aim of this study was to evaluate the laparoscopic port closure technique and to explore the factors associated with port-site incisional hernia. METHODS: Between January 2000 and January 2007, 5541 laparoscopic operations were performed by a single consultant surgeon for different indications. The ports were closed by the classical method using a J-shaped needle after release of pneumoperitoneum. The incidence of port-site incisional hernias was calculated. All patients were followed up by outpatient clinic visits and by their general practitioners. RESULTS: During a 6-year period, 5541 laparoscopic operations were performed. Eight patients (0.14%) developed port-site hernia during a mean follow-up period of 43 months (range, 25 to 96) and required elective surgery to repair their hernias. No major complications or mortality was reported. CONCLUSION: Laparoscopic port closure using the classical method was associated with an acceptable incidence of port-site hernia. Modification of the current methods of closure may lead to a new technique to prevent or reduce the incidence of port-site incisional hernias.

Laparoscopic surgery for chronic groin pain in the general population: a prospective study.

BACKGROUND: Chronic groin pain is a challenging problem among not only athletes but also the general population. The aim of this study was to evaluate the role of laparoscopic surgery in the management of these patients. PATIENTS AND METHODS: Prospective data including the outcomes were collected and analyzed for 43 patients who had groin pain without clinical or radiologic evidence of hernia. All patients had magnetic resonance imaging scan and had consulted an orthopedic surgeon when appropriate. All patients were followed in clinic 2 weeks after operation and 6 months after the operation by phone call, and all were asked to call our unit in case of partial or no improvement. RESULTS: From September 1999 to August 2006, we performed 1617 laparoscopic groin hernia repairs in 1209 patients using the transabdominal preperitoneal approach. Forty-three patients (3 women and 40 men) with variable life activities and employment were included in this study. Only five patients played football at a professional level. The mean age of these patients was 38 years (range, 17-74 years), and the mean follow-up was 43 months (range, 14-72 months).The clinical invagination test showed wide external inguinal ring in 27 (62.7%) patients and tender inguinal canal in another 6 (13.95%) patients. Negative laparoscopy was reported in 7 (16.27%) patients. All patients had mesh insertion. The operation cured groin pain in 30 (69.76%) patients, and the pain improved in another 9 (20.93%) patients. Three (6.97%) patients had no change in their symptoms, and the pain became worse in 1 (2.32%) patient. CONCLUSION: We suggest offering laparoscopic groin exploration and mesh insertion for any adult patient presenting with chronic groin pain without clinical evidence of groin hernia or radiologic abnormality regardless of age, life activities, and employment.