R. N. van Veen

Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review

BackgroundAlthough a large number of surgeons currently perform endoscopic hernia surgery using a total extraperitoneal (TEP) approach, reviews published to date are based mainly on trials that compare laparoscopic transabdominal preperitoneal (TAPP) repair with various types of open inguinal hernia repair.MethodsA qualitative analysis of randomized trials comparing TEP with open mesh or sutured repair.ResultsIn this review, 4,231 patients were included in 23 trials. In 10 of 15 trials, TEP repair was associated with longer surgery time than open repair. A shorter postoperative hospital stay after TEP repair than after open repair was reported in 6 of 11 trials. In 8 of 9 trials, the time until return to work was significantly shorter after TEP repair. Hospital costs were significantly higher for TEP than for open repair in all four trials that included an economic evaluation. Most trials (n = 14) reported no differences in subsequent recurrence rates between TEP and open repair.ConclusionsThe findings showed that endoscopic TEP repair is associated with longer surgery time, shorter postoperative hospital stay, earlier return to work, and recurrence rates similar to those for open inguinal hernia repair. The procedure involves greater expenses for hospitals, but appears to be cost effective from a societal perspective. The TEP technique is a serious option for mesh repair of primary hernias.

Nerve management during open hernia repair

Peroperative identification and subsequent division or preservation of the inguinal nerves during open hernia repair may influence the incidence of chronic postoperative pain.

Long-term follow-up of a randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia

Prospective studies and meta‐analyses have indicated that non‐mesh repair is inferior to mesh repair based on recurrence rates in inguinal hernia. The only reliable way to evaluate recurrence rates after hernia surgery is by long‐term follow‐up.

Successful endoscopic treatment of chronic groin pain in athletes.

BackgroundChronic groin pain, especially in professional sportsmen, is a difficult clinical problem.MethodsFrom January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 ± 4.5 years; range, 17–36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement.ResultsIncipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation.ConclusionsA TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.

Patent processus vaginalis in the adult as a risk factor for the occurrence of indirect inguinal hernia

BackgroundInguinal hernias are a common entity with nearly 31,000 repairs annually in the Netherlands and over 800,000 in the USA. The aim of the present study is to determine whether a laparoscopically diagnosed patent processus vaginalis (PPV) is a risk factor for the development of groin hernia.MethodsThe study population was originally composed of 599 consecutive cases (189 male, 32%) of laparoscopic transperitoneal surgery for different indications performed in 4 teaching hospitals in the Netherlands between November 1998 and February 2002. During laparoscopy, the deep inguinal ring was inspected bilaterally. The PPV group was compared with the obliterative processus vaginalis (OPV) group.ResultsAfter a mean follow-up of 5.5 years, the studied population consisted of 337 cases (94 male, 28%). In this study 12% of the studied population appeared to have PPV in adult life. The percentage PPV of our study group is much higher than the percentage of hernia repairs performed in the Dutch population. A greater proportion (12%) of hernia repairs in the PPV group was found as compared with the OPV group (3%). The chance of developing an inguinal hernia within 5.3 years is four times higher in the group with PPV. No significant correlation between age and the prevalence of PPV was observed.ConclusionThis study demonstrates that PPV is an etiologic factor and a risk factor for acquiring an indirect inguinal hernia in adults.

Authors' reply: Long‐term follow‐up of a randomized clinical trial of non‐mesh versus mesh repair of primary inguinal hernia (Br J Surg 2007; 94: 506–510)

the analysis and assessment of their respective contribution. We contend for example that the clinical status of patients at the time of arrival in the emergency department has never been appropriately taken into account in an analysis that could assess the influence of hospital delays. We propose that it makes clinical sense that delays could be associated with perforation. We propose that our analysis (post-hoc), in a limited way, suggests a role for delays when confounding is taken into account. Until an analysis has properly taken into account all the factors mentioned above, we propose that ignoring delays would make no clinical sense, especially since our results point to ways of minimizing them. If one takes the point of view of the population and not only the point of view of the surgeons, one could even argue that we could explore ways of reducing pre-hospital delays (e.g. better training of first-line clinicians and better accessibility of first-line assessments). This would potentially further increase the benefits that would result from avoidance of perforation. P. Tousignant, N. Sicard, S. Dubé and R. Pineault Direction de Santé Publique de Montréal, 1301 Sherbrooke Est, Montreal, Quebec, Canada H2L 1M3 DOI: 10.1002/bjs.5900

Authors' reply: Nerve management during open hernia repair (Br J Surg 2007; 94: 17–22)

Sir We thank Kanhere and Bridgewater for their reaction. However, they probably misunderstood us when they conclude that we propose transection of the cystic artery before obtaining the critical view for safety. The surface area of Calot’s triangle was measured: initially after opening the covering peritoneal sheath and removing all fatty tissue from the triangle. Secondly after releasing the neck of the gallbladder from its fossa (critical view of safety has been obtained), and third after ligation and transection of the cystic artery. Our conclusion therefore applies to transection of the cystic artery before cystic duct only after the critical view has been obtained and with that, the cystic artery and cystic duct have been positively identified. Transection of the cystic artery before transection of the cystic duct, displaying Calot’s triangle significantly, represents a final check with regard to the identity of the presumed cystic duct and furthermore will prevent tearing off the cystic artery. A. R. Wijsmuller, M. Leegwater, L. Tseng, H. J. Smaal, G. J. Kleinrensink and J. F. Lange Department of Surgery, Erasmus MC, University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands DOI: 10.1002/bjs.5937