H Lau

Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis : A metaanalysis

BackgroundEarly laparoscopic cholecystectomy has been advocated for the management of acute cholecystitis, but little evidence exists to support the superiority of this approach over delayed-interval operation. The current systematic review was undertaken to compare the outcomes and efficacy between early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis in an evidence-based approach using metaanalytical techniques.MethodsA search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1988 and June 2004. Only randomized or quasi-randomized prospective clinical trials in the English language comparing the outcomes of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were recruited. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio or weighted mean difference where feasible and appropriate.ResultsA total of four clinical trials comprising 504 patients met the inclusion criteria. Failure of conservative treatment requiring emergency cholecystectomy occurred for 43 patients (23%) in the delayed group. Metaanalyses demonstrated a significantly shortened total length of hospital stay in the early group (weighted mean difference, −1.12; 95% confidence interval [CI], −1.42 to −0.99; p < 0.001). Pooled estimates did not show any significant differences between the two approaches in terms of operation time, conversion rate, overall complication rate, incidence of bile leakage, and intraabdominal collection.ConclusionsThe safety and efficacy of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were comparable. Because evidence suggested that early laparoscopic cholecystectomy reduced the total length of hospital stay and the risk of readmissions attributable to recurrent acute cholecystitis, it is therefore a more cost-effective approach for the management of acute cholecystitis.

Laparoscopic repair of perforated peptic ulcer: a meta-analysis

BackgroundLaparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years, but few data exist to support the superiority of the laparoscopic approach over open repair. The objective of the current study was to compare the safety and efficacy of open and laparoscopic repair of perforated peptic ulcer in an evidence-based approach using meta-analytical techniques.MethodsA search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1990 and December 2002. Only studies in the English language comparing the outcomes of laparoscopic and open repair of perforated peptic ulcer were recruited. All reports were critically appraised with respect to their methodology and outcome. Data from all included studies were extracted using standardized data extraction forms developed a priori. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio where feasible and appropriate.ResultsA total of 13 publications comprising 658 patients met the inclusion criteria. The overall success rate of laparoscopic repair was 84.7% (n = 249). Postoperative pain was lower after laparoscopic repair than after open repair, supported by a significant reduction in postoperative analgesic requirement after laparoscopic repair. Meta-analyses demonstrated a significant reduction in the wound infection rate after laparoscopic repair, as compared with open repair, but a significantly higher reoperation rate was observed after laparoscopic repair.ConclusionsEvidence suggests that laparoscopic repair of perforated peptic ulcer confers superior short-term benefits in terms of postoperative pain and wound morbidity. This approach is as safe and effective as open repair. Laparoscopic Graham–Steele patch repair of perforated duodenal or justapyloric ulcer is beneficial for patients without Boey’s risk factors.

Learning curve for unilateral endoscopic totally extraperitoneal (TEP) inguinal hernioplasty.

Background: Performance of endoscopic totally extraperitoneal inguinal hernioplasty (TEP) requires specialized anatomical knowledge and surgical dexterity. The present study was undertaken to evaluate the learning curve for a general surgeon to master the technique of TEP in the absence of an experienced supervisor. Methods: A retrospective analysis of the first 120 consecutive unilateral TEPs was performed. Medical records were reviewed to evaluate demographic features, perioperative outcome, and follow-up results. The study population was divided into six consecutive groups of 20 patients. Clinical data were compared among the groups to evaluate the impact of operative experience on perioperative outcome. Results: Operative time was the only clinical parameter that showed significant improvement with experience; it reached a plateau value of <1 h after the fourth group. Conversions to transabdominal and open approaches were required in only one patient in groups 1 and 6, respectively. Comparison of demographic features, hernia types, postoperative morbidity rates, length of hospital stay, and number of days to resume normal activities showed no significant differences among the groups. All complications were minor and resolved uneventfully. No recurrence was detected during follow-up. Conclusions: The learning curve for unilateral TEP by a general surgeon peaked after performing 80 procedures. In most cases, unilateral TEP can be accomplished safely within 1 h. Even during the learning process, TEP carries a low morbidity and conversion rate.

Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males: a randomized trial.

BackgroundEndoscopic totally extraperitoneal inguinal hernioplasty (TEP) is an accepted technique for the repair of recurrent and bilateral inguinal hernia, but its role in the management of unilateral primary inguinal hernia remains controversial. The current randomized trial was undertaken to compare the postoperative and 1-year outcomes of day-case TEP and open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males.MethodsFrom January 2002 to January 2004, a total of 200 male patients were randomized to undergo either day-case unilateral TEP or open Lichtenstein hernioplasty under general anesthesia. The primary outcome measures included postoperative pain score, time until return to work, incidence of chronic groin pain, and recurrence rate 1 year after the operation.ResultsAll TEP procedures were successfully performed without conversion. The mean operation time for TEP (50±13.2 min) was significantly shorter than for open Lichtenstein hernioplasty (58 ± 17.6 min) (p < 0.001). The pain score at rest was significantly lower in the TEP group than in the open group on postoperative days 0, 1, 4, 5, and 6. On the average, the patients returned to work 8.6 days after TEP and 14 days after Lichtenstein hernioplasty (p = 0.006). Postoperative recovery and morbidity rates were otherwise comparable between the two groups. The incidence of chronic groin pain 1 year after TEP (9.9%) was significantly lower than after open surgery (21.7%) (p = 0.032). None of the patients in either group showed recurrence at the last follow-up assessment.ConclusionsDay-case TEP was superior to open Lichtenstein hernioplasty for the repair of unilateral primary inguinal hernia in males. The benefits of day-case TEP included less postoperative pain, a faster return to work, and a lower incidence of chronic groin pain.

Umbilical hernia in adults

Background: There is no consensus on the best technique for the repair of umbilical hernia in adults. The role of laparoscopic hernioplasty of umbilical hernia remains controversial. This study was undertaken to compare the outcomes of open and laparoscopic onlay patch repair of umbilical hernia in adults. Methods: From January 1996 to December 2002, 102 patients underwent elective repair of umbilical hernia. Operative techniques included Mayo repair (n = 43), laparoscopic onlay Gore-Tex patch hernioplasty (n = 26), suture herniorrhaphy (n = 24), and mesh hernioplasty (n = 9). Results: Demographic features and risk factors were similar among the four groups. The operative time of laparoscopic hernioplasty (median, 66 min) was significantly longer than those for patients who underwent Mayo repair (60 min) or sutured herniorrhaphy (50 min) (p < 0.05). None of the patients who underwent laparoscopic patch repairs required conversion to open repair. The median pain score at rest on postoperative day 1 was significantly lower in patients who underwent laparoscopic repair compared to those who had Mayo repair. A significantly shorter hospital stay and a lower wound morbidity rate were also observed in patients who underwent laparoscopic repair. With a mean follow-up of 2 years, suture herniorrhaphy had a relatively high recurrence rate (8.7%), whereas no recurrence was documented for the other techniques. Conclusions: Laparoscopic onlay patch hernioplasty is a safe and efficacious technique for the repair of umbilical hernia. Compared to Mayo repair, the laparoscopic approach confers the advantages of reduced postoperative pain, shorter hospital stay, and a diminished morbidity rate.

Prevalence and severity of chronic groin pain after endoscopic totally extraperitoneal inguinal hernioplasty

Background: Chronic groin pain after open inguinal hernia repair is a common long-term morbidity, but its incidence after endoscopic totally extraperitoneal inguinal hernioplasty (TEP) has not been studied in detail. The objective of this study was to evaluate the prevalence and severity of chronic groin pain after TEP. Methods: Between June 1999 and September 2001, 313 consecutive patients who underwent TEP at our institution were recruited. To evaluate the incidence and severity of chronic pain, a cross-sectional telephone survey using a standardized questionnaire was conducted by a research assistant. Clinical data between the chronic pain group and the pain-free group were compared to identify any clinical factors that had a significant association with the subsequent development of chronic groin pain. Results: The prevalence of chronic groin pain was 9.2% (n = 24). The severity of the pain was mild (n = 18), moderate (n = 5), or severe (n = 1). In more than half of the patients, the groin pain occurred less often than once a month and its duration did not exceed 1 min. Only one patient reported an impairment of functional activities as a result of the pain. Multivariate analyses identified a significant association between a high postoperative pain score on coughing on postoperative day 6 and the subsequent development of groin pain. Conclusions: The prevalence of chronic groin pain in patients after TEP was low. The pain was mostly mild and transient without associated sensory symptoms. The occurrence of pain had a negligible impact on daily activities.

Seroma following endoscopic extraperitoneal inguinal hernioplasty

Background: Because it mimics a postoperative recurrence of hernia, seroma has been a concern to patients. There has been no consensus on the management of this condition after endoscopic totally extraperitoneal inguinal hernioplasty (TEP). The objectives of the present study were to evaluate the incidence and treatment of seroma after TEP. Risk factors for the development of seroma were also examined. Methods: A total of 450 consecutive patients who underwent TEP between June 1999 and May 2002 were recruited. All data were collected prospectively. The outcomes of patients who developed seromas were compared to those without this postoperative complication. Regression analysis was performed to identify independent risk factors for seroma formation. Results: The overall incidence of seroma formation was 7.2% (n = 40). The postoperative recovery of patients was not influenced by the development of seroma. The mean size of the seromas was 3.8 cm. Adopted treatment strategies included observation (n = 29), oral lysozyme (n = 10), and percutaneous aspiration (n = 3), but neither of the two interventions appeared to be effective. The seromas resolved spontaneously by an average of 2.4 (mean) months. Significant clinical factors associated with seroma formation included old age, large hernial defects, an extension of the hernia into the scrotum, and the presence of a residual distal indirect sac. By logistic regression, a large hernial defect and an extension of the hernia into the scrotum were found to be independent risk factors for seroma formation. Conclusions: Although seroma is a frequent minor morbidity after TEP, it has no impact on postoperative recovery. Because all seromas invariably resolve, expectant treatment with observation is recommended. Inguinoscrotal hernia carries a four-fold increased risk of developing seroma after TEP.

Acute pain after endoscopic totally extraperitoneal (TEP) inguinal hernioplasty: multivariate analysis of predictive factors

Background: Pain is the most common complaint after inguinal hernia surgery. The present study was undertaken to evaluate the significance of various perioperative clinical factors on the severity of postoperative pain following endoscopic totally extraperitoneal (TEP) inguinal hernioplasty.Methods: Between November 1999 and December 2002, 509 patients who underwent unilateral (n = 389) and bilateral (n = 120) TEP were recruited for this study. There were 491 men and 18 women. Severity of postoperative pain at rest and on coughing was assessed by a linear analogue pain score (scale, 0–10) on a daily basis after operation. Univariate and multivariate analyses were performed to identify the significant independent factors affecting pain. Results: By univariate analysis, pain scores at rest were significantly higher in young (≤65 years) female patients, as well as patients who underwent unilateral and day case TEP. Clinical factors associated with a significantly higher pain score on coughing included mesh fixation by stapling, female sex, and age (≤65 years). Other factors, including unilateral vs bilateral TEP, seroma formation, direct vs indirect hernia, primary vs recurrent hernia, and operative time, had no impact on postoperative pain. On multiple regression analysis, age and sex were found to be independent predictive factors for mean daily pain score at rest. Independent factors influencing mean pain score on coughing included age, sex, and prosthetic stapling. Conclusions: Patient age and sex are the most significant factors determining the degree of pain after TEP. Analgesic therapy should therefore be adjusted in accordance with the age of the patient. With regard to operative factors, avoidance of prosthetic stapling might help to reduce the severity of pain on coughing.

Management of peritoneal tear during endoscopic extraperitoneal inguinal hernioplasty

Background: Peritoneal tear during endoscopic extraperitoneal inguinal hernioplasty (TEP) results in pneumoperitoneum and loss of extraperitoneal space. To avoid bowel adhesions, internal herniation, and mesh migration, closure of the peritoneal opening is preferred. The present study was conducted to evaluate the efficacy of various operative techniques for the closure of peritoneal laceration. Methods: Between April 2000 and May 2001, 100 consecutive patients undergoing 123 TEPs were recruited for the present study. The incidence of peritoneal tear and techniques for the closure of peritoneal opening were documented. Operative time and postoperative morbidity were compared among groups for which different closure methods of peritoneal laceration were used. Results: The incidence of peritoneal tear was 47%. The mean operative times of unilateral TEPs with and without peritoneal laceration were 66 min and 53 min, respectively (p<0.05). Techniques for the closure of the peritoneal opening included endoscopic stapling (n = 12), endoscopic suturing (n = 14), and pretied suture loop ligation (n = 21). The mean operative times for unilateral TEPs with endoscopic stapling, pretied suture loop ligation, and endoscopic suturing of peritoneal tear were 53, 64, and 82 min, respectively (p<0.05). Comparison of postoperative morbidity showed no significant differences among the three groups. Conclusion: Peritoneal tear is a frequent and challenging intraoperative event during TEP. Its occurrence significantly prolongs the length of operation. Endoscopic stapling and pretied suture loop ligation are safe and quick techniques for the closure of peritoneal tear during TEP.

Urinary retention following endoscopic totally extraperitoneal inguinal hernioplasty.

AbstractsBackground: The impact of preperitoneal mesh after endoscopic totally extraperitoneal inguinal hernioplasty (TEP) on voiding function has not been previously examined. The objectives of the present study were to evaluate the incidence of and risk factors for urinary retention following TEP. Methods: Three hundred consecutive patients who underwent TEP between June 1999 and September 2001 were recruited. Patient records were reviewed retrospectively to identify those who developed postoperative urinary retention. For each case patient, five age-matched control patients were randomly selected. We then compared the clinical data for the case and control groups. A prospective study of uroflowmetry in patients who underwent bilateral TEP was conducted to evaluate the effect of preperitoneal mesh on voiding function. Results: The overall incidence of urinary retention following TEP was 4% (n = 12). Patients who developed urinary retention stayed in hospital for a significantly longer period than the control group. No significant association was found between the clinical data and postoperative urinary retention. Bilateral TEPs were not associated with significant deterioration in uroflowmetry. Conclusions: Urinary retention is a frequent morbidity after TEP and significantly prolongs the length of hospital stay. Preperitoneal Prolene mesh did not cause outflow obstruction or alter bladder contractility. No specific clinical factors were identified that might predict postoperative urinary retention, which was probably multifactorial in causation in our patient population.