J R Coll Surg. Edinb., 43, February 1998, 13—16

Prospective audit of 200 patients undergoing laparoscopic inguinal

hernia repair with follow-up from 1 to 4 years

P. KIRUPARAN AND S. H. PETTIT
Department of Surgery, Victoria Hospital, Blackpool, UK

The results of 215 laparoscopic transabdominal pre-peritoneal inguinal hernia repairs are reported with a follow-up of 1-4 years (median 2.5 years). The patients’ age range was 17-85 (median 59 years). Three recurrences occurred in the first 75 repairs, where a 12 x 7 cm mesh was used. There has been no recurrence in the subsequent 140 repairs where a larger 15 x 10 cm mesh was used for the repair. A total of 5% of patients developed urinary retention after the operation and a further 13% developed minor complications. The procedure was remarkably pain-free, with 25% requiring no analgesia after the operation and 67% requiring no analgesia after discharge from hospital. There was a rapid return to normal activity, with 55% driving within 1 week of the operation and 85% within 2 weeks. Sixty per cent returned to work within 2 weeks of the operation and 69% within 3 weeks. Forty-two of the patients had undergone a previous open hernia repair and 93% of these preferred the laparoscopic repair as there was less post-operative pain and a quicker recovery. The results show that laparoscopic hernia repair is remarkably pain-free, allows a rapid return to normal activity and has a low recurrence rate when a 15 x 10cm mesh is used.

Keywords: inguinal hernia repair, laparoscopy

Laparoscopic inguinal hernia repair is a relatively new operation and its role in general surgical practice remains controversial.1 Initial reports suggest that it is a safe operation with a low major complication rate and a rapid and relatively pain-free recovery.2 Concerns have, however, been raised about its long-term recurrence rate3 and continued audit of this new technique is therefore essential. We present our experience of 200 consecutive patients undergoing laparoscopic transabdominal pre-peritoneal hernia repair with 1-4 years of follow-up.

PATIENTS AND METHODS

Between August 1992 and September 1995, 200 consecutive patients undergoing laparoscopic hernia repair were studied. Peri-operative data were collected prospectively. As this is a new operation undergoing evaluation, all the operations were performed by one consultant.

After the induction of general anaesthesia, 500 mg of metronidazole and 1.5 g of cefuroxime were given intravenously. A Veress needle was introduced above the umbilicus and 4 L of CO, insufflated at a pressure of 14 mmHg. A 10 mm trocar was inserted above the umbilicus followed by the insertion of a laparoscope and inspection of the peritoneal cavity. A 5mm trocar was inserted on the ipsilateral side of the hernia and a 12 mm trocar on the contralateral side, both being in the mid-clavicular line 2cm below the umbilicus. With bilateral hernia repairs, two 12 mm trocars were used. The hernia orifice was identified and the peritoneum incised transversely 3 cm above the deep inguinal ring. A flap of peritoneum was then dissected inferiorly to expose the neck of the hernia. The hernial sac, if small, was then invaginated and the dissection continued to separate the hernial sac and peritoneal flap away from the cord structures inferiorly.

The dissection was continued medially until the mid-point of the symphisis pubis was exposed and laterally far enough to accommodate the mesh. With large indirect hernias the neck of the sac was divided at the deep ring and the dissection continued as above, leaving the distal end of the sac in situ. With bilateral hernias, the dissection was performed first on one side and then continued on the other side until the dissected spaces met over the mid-point of the symphisis pubis. With unilateral hernias a 15 x 10 cm polypropylene mesh was then placed over the hernia orifice and stapled to the symphisis pubis and inferior pubic ramus using 4 mm staples (Endohernia stapler, Autosuture). The medial, superior and lateral margins of the mesh were then stapled to the abdominal wall muscle using 4.8 mm staples, care being taken to avoid the inferior epigastric vessels and to avoid placing staples inferior to the iliopubic tract on the lateral margin of the mesh. The mesh was then covered by stapling the peritoneal flap back together along the line of the original incision using 4.8 mm staples. With bilateral hernias, a 30 x 10 cm polypropylene mesh was used to cover both hernial orifices. The 10 and 12 mm trocar sites were then closed with 0 Maxon. A 20-mL of volume of 0.5% bupivocaine was infiltrated into the trocar sites and the skin closed with 3/0 subcuticular Vicryl and steristrips.

All of the patients were prescribed opiate and oral analgesics. The type of analgesic given post-operatively, if any, was left to the discretion of the attending nursing staff. The patients were encouraged to mobilize, drink and eat when they felt able and were discharged when they felt comfortable. All patients were seen in the outpatient department 6 weeks after the operation and detailed records of their progress and any complications were made. All patients were then sent a questionnaire before completion of this study, enquiring about analgesics taken after discharge from hospital, length of time to driving and to resuming work.

All patients were asked to give an assessment of their satisfaction with the outcome of the operation ranging through very good, good, fair and poor. All patients who had previously undergone an open hernia repair were asked to make a comparison between their former open repair and the laparoscopic repair, and to specifically comment on differences in post-operative pain and the rate of return to normal activities. Patients who did not return their questionnaires were followed-up by phone call.

RESULTS

Laparoscopic transabdominal pre-peritoneal hernia repairs were successfully performed on all 200 patients. Four patients also underwent laparoscopic cholecystectomy and three umbilical hernia repair under the same anaesthetic. There was a 100% follow-up rate; 80% of patients returned their questionnaires, the remainder being followed-up by phone. Demographic data on the patients and their hernias are given in Table 1. A histogram of their age distribution is shown in Figure 1.

Table 1 Demographic data on patients and hernias

Number of hernias 215
Type of hernia  
Unilateral 185
Bilateral 15
Primary 195
Recurrent 20
Indirect 136
Direct 72
Sliding 5
Pantaloon 2
Previous open hernia repair on contralateral side 22
Number of patients 200
Male: female 191:9
Median (range) age (years) 59 (17-85)
Median (range) follow-up (years) 2.5 (1.4)

 

Figure 1 Histogram showing ages of patients undergoing laparoscopic hernia repair.
   

The mean operative time for unilateral hernias was 36 minutes and for bilateral hernias 51 minutes. All of the patients were admitted for overnight observation after the operation. Most were discharged after one or two nights (Table 2). Twenty-seven patients stayed in for three or more nights, usually because of retention of urine or for social reasons with older patients. We were impressed by the relative lack of pain after the operation and the early return to normal activities in most patients (Table 2). Twenty-five percent of patients did not require any analgesia while in hospital and 67% did not require analgesia after discharge. Over half the patients were driving within 1 week of the operation and 69% had returned to work within 3 weeks of the operation. Most patients were satisfied with the outcome of their laparoscopic hernia repairs, 92% describing the outcome as good or very good (Table 2). The 6% who described the outcome as poor had all developed complications (Table 3). Forty-two patients had previously undergone an open hernia repair; 93% of these reported less pain and a quicker return to normal activity with their subsequent laparoscopic hernia repair (Table 4).

 

Table 2 Details of hospital stays, analgesia required, recovery times and patients’ assessment of laparoscopic hernia repair. Values are No. (%) or % only

Post-operative stay in hospital  
1 night 102(51)
2 nights 71(35.5)
3 or more nights 27(13.5)
Analgesia required in hospital  
None 25
Oral 28
One opiate injection 20
Opiate injection(s) and oral 27
Analgesia required after discharge  
None 67
Oral 33 (for an average of 4.6 days)
Time taken to resume driving  
Within 1 week of operation 55
Within 2 weeks of operation 85
Time taken to resume work  
Within 2 weeks of operation 60
Within 3 weeks of operation 69
Patients’ assessment of operation  
Very good 83
Good 9
Fair 2
Poor 6

Table 3 Non-fatal complications after laparoscopic hernia repairs in 200 patients. Values are number of patients

Total number of complications 38
Retention of urine 11(2 requiring TURP)
Seroma 9 (5 requiring aspiration)
Scrotal bruising 7
Neuralgia 4
Orchalgia 3
Injury to lateral cutaneous nerve of thigh 2
Cellulitis around umbilical port site 2

Table 4 Patients’ comparison of laparoscopic hernia repair with previous open hernia repair. Values are numbers of patients

Total number of patients 42
Recurrent ipsilateral hernia 20
Previous open hernia repair on contralateral side 22
Less pain and quicker recovery with laparoscopic repair 39
Less pain and quicker recovery with open repair 2
No difference 1

Operative complications

One bladder injury occurred early in our series. The bladder defect was repaired laparoscopically and the patient was discharged the following day with an indwelling urinary catheter. A cystogram was performed 10 days after the operation to exclude leaks and the catheter was then removed. No vascular, bowel or cord injuries occurred in any of our patients.

Post-operative complications

Nineteen per cent of patients developed complications after the operation (Table 3). Some, such as bruising and transient orchalgia were minor and were only noted because of careful questioning at follow-up. A total of 5.5% developed urinary retention after the operation, probably reflecting the age range of the patients (Figure 1). Two patients early in our series sustained staple injuries to their lateral cutaneous nerves of thigh, causing impaired cutaneous sensation in their outer thighs (Table 3). Both recovered spontaneously after several months. One patient died 3 days after the operation due to myocardial infarction. He was a previously fit 82-year-old who gave no history of coronary artery disease. He appeared to make a good recovery after the operation and was fully mobile and due to be discharged home on the day that the myocardial infarction occurred. No port hernias have occurred in any of our patients.

Recurrences

Three hernias recurred out of the 215 hernias repaired, a recurrence rate of 1.4%. All three recurrences occurred in the first 75 repairs at 4 weeks, 8 months and 11 months after the operation. During the first year of the study (75 repairs) a 12 x 7 cm polypropylene mesh was being used for the hernia repair. In the subsequent 2 years, (140 repairs) a 15 x 10 cm polypropylene mesh was used. There have been no recurrences in this subgroup of patients who have now been followed-up for 1—3 years.

DISCUSSION

This study represents the early experience of transabdominal preperitoneal hernia repair by a single surgeon. The operative technique evolved as complications were encountered. The one bladder injury in this series occurred very early in our experience and is a learning curve phenomenon. With adequate supervision bladder injuries should not occur during laparoscopic hernia repair. The two lateral cutaneous nerve of thigh injuries occurred because staples were placed on the lateral margin of the mesh below the level of the iliopubic tract.4 After these two injuries were recognized, care was taken to avoid placing staples below the iliopubic tract and further injuries have not occurred.

It is now recognized that a 15 x 10 cm mesh should be used for unilateral laparoscopic hernia repair. Smaller meshes are inadequate and their use wilI predispose to hernia recurrence.5 There have been no recurrent hernias in the last 140 patients in this series where a 15 x 10cm mesh was used with a follow-up of 1-3 years. Although longer follow-up is required, these results are encouraging and suggest that recurrence rates for laparoscopic hernia repair could equal those of the current gold standard operation for open hernia repair, the Lichtenstein technique, where recurrence rates of 0.5% have been reported.6

Some complications such as bruising, seroma formation and urinary retention are inevitable after any form of hernia repair and little can be done to prevent them. Neuralgic pain can be a particularly distressing complication, occurring in an estimated 1- 2% of open hernia repairs.4 It is caused by entrapment of the ilioinguinal or iliohypogastric nerves in the repair or subsequently formed scar tissue. As these nerves run between the muscle layers of the abdominal wall, neuralgia can only occur in laparoscopic hernia repair if the nerves are trapped by the staples used to anchor the mesh, as the dissection is entirely pre-peritoneal. Four patients developed neuralgia in our series (2%) and in one case this was severe, preventing return to work for many months. The risks of neuralgia occurring after laparoscopic hernia repair can be minimized by using helical titanium tacks (Origin Tacker, Origin) to anchor the mesh instead of staples. This is now our preferred technique. The titanium tacks are inserted via a 5 mm port, which gives an added advantage over staples which require a 12 mm port.

The one death in this series is worrying, but we believe that this may have occurred regardless of the type of hernia repair performed, as the patient had made a full recovery from anaesthesia and the operation. Published work suggests that laparoscopic hernia repair is a safe operation with a very low mortality. In one multi-centre study of over 1500 laparoscopic hernia repairs, no death related to hernia repair was reported.7

We have been impressed by the low level of pain experienced by our patients undergoing laparoscopic hernia repair and by their rapid return to normal activity (Table 2). A total of 93% of our patients who had previously undergone an open hernia repair reported less pain and a quicker recovery with their subsequent laparoscopic repair. Seven prospective trials (Table 5) have been performed comparing laparoscopic hernia repair with open hernia repair.8-14 As laparoscopic hernia repair is a new technique, these trials report only short-term results. The trials include learning curve data with laparoscopic repairs, but not with open repairs, favouring the latter and making a true comparison difficult. Nevertheless, five of the seven trials showed that laparoscopic hernia repair resulted in a quicker recovery than open hernia repair8-12 and four trials showed that the laparoscopic repair was associated with less pain than open hernia repair.8-10,14 Three trials concluded that more complications arose in patients undergoing laparoscopic repair,8,13,14 but this may have been because inexperienced laparoscopic hernia repair was being compared with experienced open hernia repair.

Table 5 Summary of results of previous prospective trials comparing laparoscopic and open hernia repairs

Series Number of laparoscopic hernia repairs Recovery Pain Complication
Brooks5 43 Laparoscopic quicker Less with laparoscopic More with laparoscopic
Stoker et al.9 75 Laparoscopic quicker Less with laparoscopic Laparoscopic same as open
Millikan et al.10 75 Laparoscopic quicker Less with laparoscopic Laparoscopic same as open
Wilson et al.11 121 Laparoscopic quicker Laparoscopic same as open Laparoscopic same as open
Dunn et al.12 100 Laparoscopic quicker Laparoscopic same as open Laparoscopic same as open
Maddern et al.13 42 Laparoscopic same as open Laparoscopic same as open More with laparoscopic
Lawrence et al.14 58 Laparoscopic same as open Less with laparoscopic More with laparoscopic

 

Our results suggest that laparoscopic hernia repair performed by an experienced surgeon is a safe operation which produces less pain and has a quicker recovery than open hernia repair. It has a low recurrence rate when a 15 x 10 cm mesh is used. A randomized prospective study with long-term follow-up comparing laparoscopic hernia repair with Lichtenstein open hernia repair, performed by surgeons who have completed the learning curve in both procedures, is required to establish which is the true gold standard operation for hernia repair.

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Paper accepted 7 April 1997

Correspondence: Mr S. H. Pettit, Department of Surgery, Blackpool Victoria Hospital NHS Trust, Whinney Heys Road, Blackpool, Lancs FY3 8NR, UK.

© The Royal College of Surgeons of Edinburgh, J.R. Coll. Surg., Edinb., 43, February 1998, 13-16.