Minimally invasive hernia surgery

Abstract

Minimally invasive laparoscopic and open tension-free techniques have been evolved during the 1990's. Different laparoscopic techniques have been used, where the totally extraperitoneal hernioplasty (TEP) is a technically demanding but probably a better approach to minimally invasive hernia surgery than the transabdominal preperitoneal technique (TAPP), which may increase the risk of adhesions and postoperative intestinal obstruction. TEP has been criticized because of expensive disposable equipment. The standard polypropylene mesh used in tension-free operations induces a strong foreign tissue reaction with potentially harmful effects. A mesh with less polypropylene could possibly be beneficial.

The aim of this thesis was to evaluate and compare different minimally invasive techniques and meshes for inguinal hernia.

In three randomized controlled multi-center studies 1212 patients were randomized and included in follow-up: TEP with or without the use of a dissection balloon (322 patients); TEP using only reusable instruments, mesh-plug or Lichtenstein (299 patients); Lichtenstein with Prolene or Vyproll (which contains less polypropylene) mesh (591 patients). In the last study all randomization and entering of data was performed online in a database through the Internet, which facilitated the completion of the trial. More than 80% of all patients in the studies were operated on in day- surgery.

There were more conversions to TAPP or an open technique if a balloon not was used. However the majority of the conversions occurred early in the learning curve, which indicates that the use of a dissection balloon can be helpful during the learning curve, but in experienced hands it just adds costs to the operation, without offering additional benefits.

The operation time was shorter in the mesh-plug group compared to Lichtenstein and TER Postoperative pain was diminished after TEP compared to open repair. The time to return to work was shorter after TEP than Lichtenstein (5 vs. 7 days). The time of rehabilitation was shorter after TEP than mesh-plug or Lichtenstein (14 vs. 24.5 vs. 28.5 days). There was a tendency of more pain after Lichtenstein than after TEP or mesh-plug at follow-up. Laparoscopic hernioplasty (TEP) is superior to tension-free open herniorrhaphy with Mesh-plug and patch or Lichtenstein's operation in terms of postoperative pain and rehabilitation.

There was no significant difference between Lichtenstein with Prolene or Vyproll concerning postoperative pain, complications, rehabilitation or quality of life.

All patients (n=33 275) with a unilateral primary inguinal or femoral hernia with only one operation recorded in the Swedish Hernia Register 1992-2000 were linked to the Swedish Inpatient Register and the Swedish Death Register for the period 1987-2000. The highest adjusted relative risk (RR) of postoperative intestinal obstruction was found in patients with previous multiple admissions for abdominal operations/inflammations, including intestinal obstruction, 58.99. The RR was 2.79 with TAPP and 0.57 with TEP compared to Lichtenstein operated patients.