Bilateral inguinal hernia repair: laparoscopic or open approach?

BACKGROUND: The aim of this study was to investigate outcomes in the treatment of bilateral inguinal hernia, comparing the laparoscopic totally extraperitoneal (TEP) and open tension-free mesh repair (LICHT) approaches. METHODS: We performed a prospective controlled non randomized clinical study in 128 patients with bilateral inguinal hernia over a period of 3 years. LICHT was used in 106 cases (53 patients) while TEP was employed in 150 cases (75 patients). The main outcome measurements were: recurrence rate, operating time, hospital stay and postoperative complications. RESULTS: There were three recurrences (2.3%): two in the LICHT group (3.8%) and one (1.3%) in the TEP group P = NS. The TEP procedure was faster than LICHT repair (48.8 ± 10.8 vs. 70.4 ± 11.2 min) P < 0.01. Postoperative complications were more frequent in LICHT group (16%) than TEP group (5.3%) P < 0.01. Hospital stay was significantly shorter in the TEP group (0.6 ± 0.8 vs. 1.3 ± 1.2 days) P < 0.001. CONCLUSIONS: The TEP approach is an effective option for the treatment of bilateral inguinal hernia when performed by experienced surgeons.

Unusual upper gastrointestinal diseases associated with achalasia: laparoscopic approach.

BACKGROUND: As a result of the high success rate associated with the laparoscopic approach for achalasia, surgery for the disease has become the treatment of choice in recent years. With the greater number of patients undergoing surgery, surgeons may encounter other upper gastroesophageal illnesses associated with achalasia, and these may require evaluation for simultaneous surgical treatment. This study aimed to evaluate the incidence of gastroesophageal diseases associated with achalasia, and to determine the possibility for simultaneous management using the laparoscopic approach. METHODS: From January 1999 to May 2006, 81 patients were referred from the Service of Gastroenterology to the Service of General and Digestive Surgery as candidates for the surgical management of achalasia. Data for this group were recorded prospectively in laparoscopic surgery databases at the Hospital Sant Pau and the Hospital de Igualada. A total of 78 patients underwent laparoscopic Heller myotomy with gastric fundoplication. RESULTS: In 8 of 81 patients, nine additional gastroesophageal diseases (11.1%) were found: three cases of pseudoachalasia (3.7%), three cases of paraesophageal hiatal hernia (3.7%), two cases of esophageal diverticulum (2.5%), and one case of gastric volvulus (1.2%). Pseudoachalasia was diagnosed for three patients. The diagnosis was made preoperatively for one of these patients. For the other two patients, an adenocarcinoma arising from the gastroesophageal junction was diagnosed during the laparoscopy. In three cases, a paraesophageal hiatal hernia was found and treated by laparoscopic Heller myotomy, sac excision, hiatal closure, and posterior fundoplication. Esophageal diverticulectomy was performed for one patient. Another patient presented with an organoaxial gastric volvulus associated with achalasia, for which laparoscopic Heller myotomy, posterior fundoplication, and anterior gastropexy were performed. The median follow-up period was 39 months, with no recurrence. CONCLUSIONS: Despite their infrequency, several gastroesophageal diseases may be found in association with achalasia. Laparoscopic surgery may be useful for the diagnosis and/or treatment of both diseases.

Preperitoneal repair for recurrent inguinal hernia: laparoscopic and open approach.

BACKGROUND: The aim of this study was to investigate the outcome of preperitoneal repair using laparoscopic (TEP) and open (OPM) approach in recurrent inguinal hernia. METHODS: We performed a prospective controlled nonrandomized clinical study in 188 patients with 207 recurrent inguinal hernias over a period of 5 years. TEP repair was employed for 86 repairs, and OPM was used in 121 procedures. The main outcome measurements were: recurrence rate, operating time, hospital stay, and postoperative complications. RESULTS: There were three recurrences (1.7%). Two in the OPM group (1.8%) and one (1.3%) in the TEP group [ P=NS (not significant)]. The TEP procedure was faster than OPM for unilateral repair (40.8 vs 46.3 min) (P<0.001). Postoperative complications were more frequent in the OPM group (23.9%) than the TEP group (13.9%) ( P=NS). Hospital stay was significantly shorter in the TEP group (1.2 vs 3.9 days) (P<0.001). CONCLUSIONS: Preperitoneal approach (open or laparoscopic) seems to be a good option in recurrent inguinal hernia when these procedures are done by experienced surgeons.

The impact of the surgeon's experience on the results of laparoscopic hernia repair.

BACKGROUND: The aim of this study was to evaluate our experience with the totally extraperitoneal (TEP) laparoscopic approach to hernia repair. METHODS: We performed a prospective study of 1227 hernia repairs using the TEP technique over a 7-year period. The main outcome measurements were postoperative complications, conversion rate, learning curve effect, surgery time, hospital stay, return to work, and recurrence rate. RESULTS: The mean operating time was > 60 min during the first 50 cases, but it fall to 32 min for the last 200 cases (p < 0.05). The conversion rate was 5.7% (56 patients); declining from 17% in the first 100 cases to 2.2% for the final 500 cases (p < 0.01). There were 79 complications (6.4%) and 23 recurrences (2.3%); 42% of the complications and 61% of the recurrences appeared in the first 100 cases (p < 0.05). CONCLUSION: This study shows that postoperative complications, conversion rate, operating time, and recurrences are all substantially reduced as the surgeon's experience increases. Thus, once the learning curve is surpassed, TEP repair represents a good alternative to open techniques.

Tratamiento laparoscópico de la hernia inguinal / Laparoscopic treatment of the inginal hernia

El tratamiento laparoscópico de la hernia inguinal sigue siendo uno de los procedimientos laparoscópicos más cuestionados ya que todavía no se han demostrado claramente las ventajas de este método sobre el tratamiento clásico anterior. Se presenta una breve historia de la cirugía laparoscópica de la hernia, describiéndose la técnica totalmente extraperitoneal utilizada hoy día por los autores, así como los resultados obtenidos en 1.177 hernioplastias laparoscópicas realizadas por ellos en los últimos 6 años, destacando una recidiva del 2,1 por ciento y la progresiva mejora de resultados al aumentar la experiencia. Se revisan los estudios publicados por grupos especializados en hernioplastia laparoscópica y aquellos que la comparan con la cirugía abierta en cuanto a análisis del coste económico, resultados, curva de aprendizaje, indicación y diferencias entre los tipos de hernioplastia laparoscópica. Los resultados actuales obtenidos por grupos con experiencia son equiparables o superiores a las técnicas abiertas, si bien aspectos como el coste económico deben mejorarse. En espera de estudios prospectivos a largo plazo que definan el papel real de la hernioplastia laparoscópica en la cirugía de la hernia, creemos que la técnica totalmente extraperitoneal constituye la mejor alternativa en el tratamiento de la hernia recidivada y bilateral. En la hernia primaria unilateral debería reservarse para pacientes laboralmente activos en los que la disminución de la baja laboral pueda compensar el mayor coste hospitalario. (AU)

Evolution of laparoscopic cholecystectomy in the regional hospitals of Catalonia.

OBJECTIVE: to assess the safety and effectiveness of laparoscopic cholecystectomy in the hands of surgeons with different amounts of experience in laparoscopic surgery at 15 regional hospitals, and to analyze the evolution of the current performance in comparison with results published in 1993. METHODS: prospective study of 1168 laparoscopic cholecystectomies done in 1996 in 15 regional hospitals in Catalonia. RESULTS: in 887 cases (76%) the indication was uncomplicated cholelithiasis. Preoperative cholangiography was done selectively in 12 of the 15 hospitals. Preoperative endoscopic retrograde cholangiopancreatography was positive in only 50 cases (57.4%), with 9 complications (10.3%). In 87 patients (7.4%) conversions to open surgery occurred. Postoperative complications (6. 3%), bile duct injury (0.4%), reintervention (0.4%) and postoperative stay (2.8 days) decreased in comparison with the year 1993. CONCLUSIONS: the current results suggest an overall improvement in comparison with the 1993 findings, since the rate of complications and length of stay decreased. However, the increasing number of conversions was notable; this may be due to the increasing complexity of the indications and the rise in the number of surgeons still on the learning curve. Laparoscopic cholecystectomy is, in our setting and for many surgeons, a safe and effective procedure that yields results similar to those in other multicenter studies.

Evolución de la colecistectomía laparoscópica en los hospitales comarcales de Cataluña* / General and Digestive Surgery Department. Igualada General Hospital. Barcelona, Spain

OBJETIVO: valorar la seguridad y eficacia de la colecistectomía laparoscópica en hospitales de ámbito comarcal con un grupo amplio de cirujanos de experiencia variable en cirugía laparoscópica. Analizar la evolución de los resultados actuales comparándolos con los obtenidos y publicados por el mismo grupo en 1993. MÉTODOS: estudio prospectivo sobre 1.168 colecistectomías laparoscópicas practicadas durante 1996 en 15 hospitales comarcales de Catalunya. RESULTADOS: en 887 casos (76 por ciento) la indicación fue una colelitiasis no complicada. La colangiografía peroperatoria se realiza de forma selectiva en 12 de los 15 hospitales. La colangiopancreatografía retrógrada endoscópica preoperatoria fue positiva sólo en 50 casos (57,4 por ciento), refiriéndose nueve complicaciones (10,3 por ciento). Se han producido 87 (7 4 por ciento) conversiones a cirugía abierta. Las complicaciones postoperatorias (6,3 por ciento), lesión biliar (0,4 por ciento), reintervenciones (0,4 por ciento) y estancia postoperatoria (2,8 días) han disminuido respecto a 1993. CONCLUSIONES: los resultados actuales sugieren una mejoría global respecto a los obtenidos en 1993, ya que han disminuido las complicaciones y la estancia hospitalaria. Sin embargo, destaca el aumento de conversiones que podría atribuirse a la mayor complejidad de las indicaciones y la progresiva incorporación de cirujanos en plena curva de aprendizaje. La colecistectomía laparoscópica es, en nuestro medio y para un amplio número de cirujanos, un procedimiento seguro y eficaz, con unos resultados equiparables a los publicados por otros grupos multicéntricos similares (AU)

Laparoscopic repair of recurrent hernias.

BACKGROUND: Recurrence after primary conventional inguinal herniorrhaphy occurs in approximately 10% of patients depending on the type of repair and expertise of the surgeon. The repair of the resulting recurrent hernia is a daunting task because of already weakened tissues and obscured and distorted anatomy. The failure rate of these repairs using an open anterior approach may reach as high as 36%. Because of such a high failure rate, a number of investigators have focused on repairing these difficult recurrent hernias laparoscopically using a tension-free approach. Some of the earlier reports suggested a low recurrence rate of 0.5% to 5% when a laparoscopic approach was used to repair these hernias. The purpose of this study was to evaluate the efficacy of laparoscopic treatment for recurrent hernias in our institutions. METHODS: Between February 1991 and February 1995, 96 recurrent hernias were repaired in 85 patients (78 men and 7 women). There were 48 right, 26 left, and 11 bilateral hernias. The mean age of the patients was 59 years (range, 18-86 years); the mean height was 69 in. (range, 54-77 in.); and the mean weight was 176 pounds (range, 109-280 pounds). A total of 68 herniorrhaphies were performed using the transabdominal preperitoneal (TAPP) method: 19 using intraperitoneal on-lay mesh (IPOM) repair and 8 using the total extraperitoneal (TEP) method. The method of repair in one patient was not recorded. The mean operating time was 76 min (range, 47-172 min). Thirteen patients underwent additional procedures. RESULTS: Long-term follow-up was performed by questionnaire, examination, or both in 76 patients (85 hernias). Median follow-up time was 27 months (range, 2-56 months). There were four recurrences (2 in IPOM and 2 in TAPP). Three of these were repaired laparoscopically and one conventionally. There were 20 minor and 14 major complications and no mortality. One conversion occurred in the TAPP group. Mean postoperative stay was 1.4 days (range, 0-4 days). It was felt by 92% of the patients that their symptoms were completely relieved, whereas 4% of the patients continued to exhibit symptoms for which their hernia was repaired, and 3.6% failed to answer. As reported, 86% of the patients preferred their laparoscopic repair; 1% preferred the conventional repair; and 13% failed to reply. Afterward, 77% of the patients returned to normal activity, and 35% returned to vigorous activity within 4 weeks of surgery. Satisfaction with laparoscopic repair was expressed by 92% of the patients, whereas 8% either were dissatisfied or did not answer. In the end, 95% of the patients stated that they would recommend laparoscopic hernia surgery to their family and friends. CONCLUSIONS: These preliminary data show that laparoscopic repair of recurrent inguinal hernia is a safe alternative procedure with acceptable rates of recurrence and complications.