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.

Comparison of laparoscopic and open adrenalectomy.

This review compares the outcomes of patients who have undergone laparoscopic and open adrenalectomy. Records of all patients who underwent adrenalectomy between January 1993 and December 1996 at Cedars-Sinai Medical Center, Los Angeles, were reviewed. Ten patients underwent laparoscopic, and ten patients underwent open adrenalectomy. The average age in the laparoscopic group (LA) was 48 years (range, 23-64) and 47 years (range, 28-79) in the open group (OA). The LA had smaller tumor size (2.9 +/- 2.0 versus 6.1 +/- 2.8 cm; P = 0.01), longer operative times (164 +/- 47 versus 124 +/- 29 minutes; P = 0.03), shorter length of postsurgical stay (4.1 +/- 2.5 versus 5.9 +/- 1.1 days; P = 0.05), and fewer days of parenteral pain medication (1.9 +/- 1.8 versus 3.4 +/- 1.0 days; P = 0.04). Although the differences did not reach statistical significance, LA also had lower estimated blood loss (118 +/- 158 versus 210 +/- 172 cc; P = 0.23), less time to oral intake (1.8 +/- 2.2 versus 2.8 +/- 1.3 days; P = 0.24), and less direct cost ($3645 +/- 1502 versus $5752 +/- 2948; P = 0.07). Complications of LA included one patient who had a prolonged ileus and adrenal insufficiency and another patient who required readmission for adrenal insufficiency. Complications of OA included one patient who had a prolonged ileus and one patient who had a 20 per cent pneumothorax. Laparoscopic adrenalectomy is the preferred technique in nonmalignant adrenal lesions less than 6 cm in size.