Original Article
Laparoscopic inguinal hernia repair in the Armed Forces: A 5-year single centre study

https://doi.org/10.1016/j.mjafi.2015.05.005Get rights and content

Abstract

Background

Surgery for inguinal hernia continues to evolve. The most recent development in the field of surgery for inguinal hernia is the emergence of laparoscopic inguinal hernia surgery (LIHS) which is challenging the gold standard Lichtenstein's tension free mesh repair. Our centre has the largest series of LIHS from any Armed Forces hospital. The aim of this study was to analyze the short and long term outcomes at our center since its inception.

Methods

Retrospective review of prospectively maintained data base of 501 LIHS done in 434 patients by a single surgeon between April 2008 and October 2013. Preoperative, intraoperative, postoperative and follow-up data was analyzed with emphasis on the recurrence rates and the incidence of inguinodynia.

Results

402 (92.6%) patients had primary hernias and 367 (84.6%) patients had unilateral hernias. Of the 501 repairs, 453 (90.4 %) were done totally extraperitoneal approach and 48 (9.6 %) were done by the transabdominal preperitoneal approach. The mean operative time for unilateral and bilateral repairs was 40.9 ± 11.2 and 76.2 ± 15.0 minutes, respectively. The conversion rate to open surgery was 0.6%. The intraoperative, and early and late postoperative complication rates were 1.7%, 6.2% and 3%, respectively. The incidence of chronic groin pain was 0.7% and the recurrence rate was 1.6%. The median hospital stay was 1 day (1–5 days).

Conclusion

We, in this series of over 500 repairs have demonstrated that feasibility as well as safety of LIHS at our centre with good short and long term outcomes.

Introduction

Inguinal hernias (IH) are a common surgical problem. The estimated occurrence of hernia is around 5% in the general population of which three fourths are IH.1, 2 The repair of IH is a vexing problem which has caught the attention of surgeons since the 18th century and continues to intrigue and obsess them in a search for the ideal repair.

The surgery for IH has continued to evolve from the times Marcy attempted the reduction of hernia sac and closure of the internal ring with carbolized catgut sutures.3 From the suture-tension tissue repairs and their many modifications to the tension free prosthetic repairs, the hernia surgery has come a long way. There are two mile stones in this quest for the ideal repair that has come up in the recent past. One is in the form of the Lichtenstein's tension free mesh repair (LR).4 LR became popular because of its short learning curve and low recurrence rates and has firmly established itself as the gold standard surgery for IH.5

With the advent of minimally invasive surgery in the late 20th century, it has made forays into IH surgery too. This forms the second major mile stone in the recent times. The two main techniques of laparoscopic inguinal hernia surgery (LIHS) in vogue are the totally extraperitoneal repair (TEP) and the transabdominal preperitoneal repair (TAPP). They have challenged the gold standard LR. Today, LIHS is recommended procedure for bilateral/recurrent IH.6 However the status with regards to unilateral IH is not clear. The recent NICE guidelines of 2004 recommends laparoscopic surgery as one of the treatment options for repair of IH.7

The main issues in IH surgery are recurrences and chronic groin pain.8 With the consistently reported low recurrence rates with LR, the focus is shifting to other complications and amongst them, the post-hernioplasty inguinodynia has become the major concern following these surgeries. The advantages of using a laparoscopic approach are less postoperative pain, earlier return to work, ability to deal with bilateral hernias through the same incisions, ability to address all defects of the myopectineal orifice, decreased rates of recurrences and better cosmesis.9, 10, 11, 12 These outweigh the disadvantages that include increased operative time, costs and the learning curve.13, 14

The LIHS started in the 1990s and is being rapidly adopted worldwide. In the Armed Forces, LIHS was pioneered by the first author and is being practiced since 2004. We, in this article present the results of LIHS repair performed by a single surgeon over a period of 5 years since it was started at our centre. We look at the short term as well as long term outcomes. To the best of our knowledge, this is the largest series of LIHS from any Armed Forces Hospital.

Section snippets

Material and methods

This is a retrospective review of a prospectively maintained data base of patients operated for IH at our centre. The study period was from April 2008 to October 2013. The follow up data was updated till December 2014.

The aim of this study is to evaluate the outcomes of LIHS at our centre over this period with a primary objective to evaluate the recurrence rates and chronic groin pain and secondary objective to evaluate the intraoperative and post operative complications.

Definitions

  • 1.

    Wound infections: Defined as per the CDC classification.15

  • 2.

    Chronic groin pain: Chronic pain after hernia surgery has been defined by International Association of the Study for Pain as “pain lasting for three months or more” i.e. pain persisting beyond the normal tissue healing time assumed to be 3 months.16

Results

Between April 2008 and October 2013, 501 LIHS were done in 434 patients by a single surgeon at the department of gastrointestinal surgery of our centre. Of these, 395 patients underwent TEP and 39 patients underwent TAPP. During this period, open hernia surgery was done in 18 patients. The reasons for open hernia surgery are given as Fig. 1.

Discussion

The laparoscopic path to IH repair was born with the efforts of Ger in 1982 when a simple closure of internal ring with stapler was done.17 Since then laparoscopic repairs of groin hernia have evolved and standardized in to two main approaches: Trans Abdominal Pre-Peritoneal (TAPP; Arregui 1991)18 and Totally Extra-Peritoneal (TEP; Dulucq 1991).19 Early reports showed a higher recurrence rates with LIHS.20 With evolving experience, LIHS has shown several advantages over open repair like less

Conclusion

There is an explosion of minimally invasive techniques in the field of surgery and IH repair is no exception. The advantages with this approach have led to a change in the expectation of the clientele we are treating. Thus, there is a need to adopt LIHS, compare it with the gold standard LR and adapt it to our setup if found feasible. We, in this series of over 500 repairs have demonstrated that feasibility as well as safety of LIHS at our centre with good short and long term outcomes.

Conflicts of interest

All authors have none to declare.

References (31)

  • Thomas Nicholson et al.

    Comparison of laparoscopic vs open modified Shouldice technique in inguinal hernia repair

    JSLS

    (1999)
  • Jorg Koninger et al.

    Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP

    Langenbecks Arch Surg

    (2004)
  • L. Vale et al.

    Assessing the costs and consequences of laparoscopic vs open methods of groin hernia repair: a systematic review

    Surg Endosc

    (2003)
  • W.J. Wang et al.

    Comparison of the effects of laparoscopic hernia repair and lichtenstein tension-free hernia repair

    J Laparoendosc Adv Surg Tech A

    (2013)
  • K. McCormack et al.

    Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review

    Hernia

    (2005)
  • View full text