Laparoscopic inguinal hernia repair gold standard in bilateral

Laparoscopic inguinal hernia repair:gold standard in bilateral hernia repair?Results of more than 2800patients in comparison to literature

Constantin Aurel Wauschkuhn ?Jochen Schwarz ?

Ulf Boekeler ?Reinhard Bittner

Received:29November 2009/Accepted:22February 2010/Published online:8May 2010óSpringer Science+Business Media,LLC 2010

Abstract

Background Advantages and disadvantages of open and endoscopic hernia surgery are still being discussed.Until now there has been no study that evaluated the advantages and disadvantages of bilateral hernia repair in a large number of patients.

Methods Our prospectively collected database was ana-lyzed to compare the results of laparoscopic bilateral with laparoscopic unilateral hernia repair.We then compared these results with the results of a literature review regard-ing open and laparoscopic bilateral hernia repair.

Results From April 1993to December 2007there were 7240patients with unilateral primary hernia (PH)and 2880patients with bilateral hernia (5760hernias)who under-went laparoscopic transabdominal preperitoneal patch plastic (TAPP).Of the 10,120patients,28.5%had bilateral hernias.Adjusted for the number of patients operated on,the mean duration of surgery for unilateral hernia repair was shorter than that for bilateral repair (45vs.70min),but period of disability (14vs.14days)was the same.Adjusted for the number of hernias repaired,morbidity (1.9

vs.1.4%),reoperation (0.5vs.0.43%),and recurrence rate (0.63vs.0.42%)were similar for unilateral versus bilateral repair,respectively.The review of the literature shows a signi?cantly shorter time out of work after laparoscopic bilateral repair than after the bilateral open approach.Conclusions Simultaneous laparoscopic repair of bilat-eral inguinal hernias does not increase the risk for the patient and has an equal length of down time compared with unilateral repair.According to literature,recovery after laparoscopic repair is faster than after open simulta-neous https://www.sodocs.net/doc/6713185796.html,paroscopic/endoscopic inguinal hernia repair of bilateral hernias should be recommended as the gold standard.

Keywords Unilateral hernia áBilateral hernia áInguinal hernia áEndoscopic repair

The inguinal hernia is the most common hernia,including 90%of all spontaneous hernias,and the inguinal hernia repair is the most frequently performed procedure in general surgery.In the United States more than 700,000inguinal hernias are repaired [1,2]per annum and in Germany more than 200,000.The standard method for inguinal hernia repair relied on the sutural reconstruction of the backside of the inguinal canal,as was for the ?rst stated by Bassini,until the implementation of synthetic meshes.Because of the high recurrence rate of the suture techniques [3],tension-free methods with implantation of synthetic mesh were estab-lished,whereas which the optimal approach—open/anterior or laparoscopic/endoscopic/posterior—is still being dis-cussed [4].Among the different posterior techniques that use preperitoneal mesh implantation [5–8],the transabdominal preperitoneal patch plastic repair [9](TAPP)and the total extraperitoneal [8,10](TEP)repair achieved the most

C.A.Wauschkuhn (&)

Department for General,Visceral and Thoracic Surgery,Marienhospital Stuttgart,Boeheimstrasse 37,70199Stuttgart,Germany

e-mail:constantin.aurel@wauschkuhn.de

J.Schwarz áR.Bittner

Department for General and Visceral Surgery/MIC-Center,Bethesdahospital Stuttgart,Hohenheimer Stra?e 21,70184Stuttgart,Germany

U.Boekeler

Department for Orthopedic and Traumatic Surgery,Marienhospital Stuttgart,Boeheimstrasse 37,70199Stuttgart,Germany

Surg Endosc (2010)24:3026–3030DOI 10.1007/s00464-010-1079-x

acceptance[11].There are many indications for the use of both techniques,but the TAPP is recommended especially for recurrent hernias(after preperitoneal patch plastic)and dif?cult hernias(sliding or incarcerated hernias)[11].The advantages of the TAPP are that it is easier to perform,has a better possibility of standardization,and as the possibility that diagnostic laparoscopy can be performed[12].In gen-eral,the learning curve for TAPP seems to be shorter[11]and the type of hernia can be assessed immediately as can the situation on the opposite side,so without additional incisions both sides can be adequately repaired.

The primary end point of the present study was whether the simultaneous laparoscopic repair(TAPP)of bilateral inguinal hernias has a higher risk compared to unilateral inguinal hernia repair.We also compared the results of simultaneous open with simultaneous laparoscopic bilateral repair in the literature.

Materials and methods

Patients

The operative data and postoperative outcomes of all patients operated on laparoscopically for inguinal hernia between1993and2007were prospectively collected.All patients were included in a follow-up program and were requested to attend a speci?c hernia consultation after 4weeks,1year,and5years postoperatively.Therefore, we included in this analysis all patients who were diag-nosed as having unilateral or bilateral inguinal hernia and underwent laparoscopic TAPP from1993to2007.Besides the time of disability of patients in both groups,we com-pared the duration of operation as an intraoperative parameter and morbidity,rate of reoperation,and recur-rence as long-term characteristics.Ninety-three percent of the patients were seen in the follow-up at least once, whereas the rate of follow-up was only41%after5years. Surgical technique

We performed the standard laparoscopic TAPP as previ-ously published by us[13–15].The key points of our technique are as follows:(1)The optic trocar is placed at the upper rim of the umbilicus.(2)Both working trocars are placed at the level of the navel right and left in the medioclavicular line(in contrast to repairing a unilateral hernia with placement of the contralateral trocar in a more caudal position than the trocar on the hernia side).(3)We make a wide incision of the peritoneum high above all possible hernia openings.(4)A mostly blunt dissection is made strictly along the anatomical landmarks(rectus muscle,epigastric vessels,symphysis and Cooper’s ligament,and transverse fascia)and ends in a complete anatomical dissection of the whole pelvic?oor.(5)Thor-ough hemostasis should always be performed.(6)Espe-cially important is the parietalization,which means removing all adhesions between the retroperitoneal tissue (fascia spermatica)and the peritoneum down to the middle of the psoas muscle.(7)The systematic depiction of the symphysis with preparation of the contralateral side relieves the preparation on the contralateral side during the hernia repair and thus saves time.In principle,in the case of bilateral hernias,two meshes of at least10cm915cm are implanted.The meshes are?xed mainly by clips (Ethicon Endosurgery Multi Feed EMS Stapler,Johnson& Johnson MEDICAL GmbH,Norderstedt,Germany)and in recent years increasingly by?brin glue(Tissucol,Baxter Deutschland GmbH,Unterschlei?heim,Germany).The peritoneum was closed with an absorbable running suture. Literature overview

Searching PubMed using the search terms surgical,ther-apy,bilateral,inguinal,and hernia found612articles from 1956to2008.The main focus of our search was to analyze those articles that investigated a comparison between simultaneous open and simultaneous laparoscopic/endo-scopic repair of bilateral hernias.For comparison of the two techniques,the duration of operation and postoperative disability to work were used.

Results

From April1993to December2007there were7240 patients with unilateral primary hernia(PH)and2880 patients with bilateral hernia(5760hernias)who under-went laparoscopic transabdominal preperitoneal patch plastic(TAPP)hernia repair.Of the10,120patients,28.5% had bilateral hernias.The mean duration of unilateral hernia repair was shorter than that of a bilateral hernia repair(45vs.70min),whereas the period of disability(14 vs.14days)after each procedure was the same.Adjusted for the number of hernias repaired,there was no difference in morbidity(1.9vs.1.4%),reoperation(0.5vs.0.43%),or recurrence rate(0.63vs.0.42%)between unilateral and bilateral hernia repair.An overview of the results is given in Table1.Table2gives the complications in patients operated on for bilateral hernia;they are divided into direct intraoperative,postoperative,and late complications and compared with the results of unilateral repair.

Of the612articles found in the literature,most dem-onstrate and evaluate one surgical procedure of hernia repair.Only a very few authors have compared open and endoscopic/laparoscopic bilateral hernia repair directly in

the last12years.Table3summarizes the data of the?ve studies found[16–20]with respect to the duration of the operation and the inability to work.The number of cases in the studies was between43and120,and in Velasco et al.

[20]recurrent hernias were included.All in all,the duration of the operation(partial with a large variation)was a little longer for the endoscopic/laparoscopic bilateral hernia repair than the open bilateral repair.However,there was a large difference with respect to the length of time off from work,which was13-38days shorter for the endoscopic/ laparoscopic repair.

Discussion

Sequential repair of bilateral inguinal hernias has three main disadvantages:First,anesthesia has to be given twice, doubling the risk of general complications.Second,there is a doubled limitation of mental and physical activity. Finally,the time out of work is twice as long.Thus it follows that simultaneous repair should be the standard technique for bilateral hernias.The European Hernia Society guidelines recommend,from a socioeconomic perspective,an endoscopic procedure for the active work-ing population,especially for bilateral hernias.Also,our analysis in2002of patients who had bilateral inguinal hernia repair[13]showed evidence of the advantages of bilateral laparoscopic hernia repair,although only a2-year follow-up was analyzed.

The articles discussed above[16–20]proved consider-ably the advantage of the endoscopic/laparoscopic approach,especially when the length of time the patient was unable to work,as a subjective measure of limitation of the patient,was found to be2-4weeks shorter after the endoscopic/laparoscopic repair of bilateral hernias than after open bilateral repair.

Our data con?rm the ef?ciency and security of the simultaneous endoscopic/laparoscopic bilateral hernia repair.Although the extent of preparation during surgery is considerably greater in a bilateral repair,morbidity,rate of reoperation,and recurrence are even lower when taking the number of operated hernias in bilateral repair into account. Actually,the period of inability to work is half as long for bilateral repair when adjusted for the number of operated hernias.Thus,the repair of bilateral inguinal hernias done simultaneously leads to considerable advantages not only for the individual patient but also for the economy and the health care system.A special advantage of the transab-dominal approach is the recognition of so-called‘‘occult’’

Table1Comparison of unilateral and bilateral hernia repair from1993until2007 a Adjusted for the number of hernias Patients Unilateral hernia Bilateral hernia

n=7240n=2880(5760hernias)

Duration of operation(median)(min)4570

Morbidity 1.9% 1.4%a

Reoperation rate0.50%0.43%a

Recurrence rate0.63%0.42%a

Period of disability(median)(days)1414

Table2Complications in laparoscopic unilateral and bilateral hernia repair from1993to2007

Unilateral hernias (n=7240)Bilateral hernias (n=5760)

(in2880patients)

Intraoperative complications

Bleeding/trocar186

Bowel lesion23

Urinary bladder lesion34 Spermatic cord lesion––

Other21

Change to open approach1–

Total26(0.36%)14(0.24%) Postoperative complications

Urinary retention1817

Lesion nerves/https://www.sodocs.net/doc/6713185796.html,t.1410 Bleeding94

Orchitis52 Infection of the mesh11

Urinary infection31 Phlebothrombosis4–

Bowel obstruction/

reoperation

03

Seroma/reoperation111

Other1–

Total56(0.77%)39(0.68%) Late complications

Trocar hernia4222 Testicular atrophy12 Persistent seroma3–

Chronic pain(after2years)76

Total53(0.73%)30(0.52%)

or preoperative unknown hernias on the contralateral side, which is found in about3.6%of the patients[21].In the open approach these hernias cannot be diagnosed during surgery.Similarly,in the total extraperitoneal patch plastic (TEP)technique,the indication for a bilateral procedure has to be found preoperatively[22]or additional prepara-tion of the contralateral side has to be done to diagnose a potentially existing but preoperatively undiagnosed hernia. With this approach,Bochkarev et al.[23]found an aston-ishing22%of the patients with unknown hernias on the contralateral side.On the other hand,with bilateral prep-aration in the TEP technique,the preparation of the con-tralateral side is actually unnecessary in up to78%of the patients,it takes time,and increases the risks.In contrast, with the TAPP approach,an expeditious and low-risk evaluation of the contralateral side can be carried out during diagnostic laparoscopy[24].The high rate of dis-crepancy between preoperative clinical?ndings and the intraoperative existence of bilateral inguinal hernias found by Bochkarev et al.[23]makes one question whether the preoperative diagnostics were done accurately.In sum-mary,with TAPP an unnecessary exploration of the con-tralateral side can be avoided.Furthermore,TAPP allows at the same time,timely repair in patients with occult inguinal hernias on the contralateral side[25].The inci-dence of a hernia occurring at the contralateral side after a previous bilateral exploration is low,hence a prophylactic repair on the contralateral side is not recommended on a routine basis[26].

From our point of view,from the results of our study and following the external evidence from the literature overview,TAPP can be identi?ed as the gold standard for the repair of bilateral inguinal hernias.

Disclosures Constantin Aurel Wauschkuhn,Jochen Schwarz,Ulf Boekeler,and Reinhard Bittner have no con?icts of interest or ?nancial ties to disclose.References

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n Operative time(min)Time of disability(days)Study type

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b Also recurrent hernias

c Time for one side

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