After 10 years and 1903 inguinal hernias, what is the outcome for the laparoscopic repair?

BACKGROUND: The procedure of choice for inguinal hernia repair has remained controversial for decades. The laparoscopic approach has now been utilized for more than 10 years, and a significant volume of patient outcomes is now available for review. METHODS: The hospital and office records of 1388 patients who underwent 1903 laparoscopic inguinal hernia repairs at Atlanta Medical Center during the past 10 years were retrospectively reviewed in order to determine demographics, recurrence rate, and complications. In addition, 123 hernia repairs were prospectively studied in 71 patients during this time period in order to accurately evaluate postoperative pain and return to activity. RESULTS: Two hundred fifty-five (13.4%) hernias were recurrent and 1648 (86.6%) were primary. Five hundred and fifteen (37.1%) hernias were bilateral. The total extraperitoneal approach was utilized for 1561 (82.0%) of the 1903 repairs. The average operative time was 75.4 (14-193) minutes. Estimated blood loss was 22.0 (0-250) ml. Seventeen patients (1.2%) were converted to an open form of hernia repair. Minor complications occurred in 83 (6.0%) patients and major complications occurred in 18 (1.3%) patients. CONCLUSIONS: The laparoscopic approach is a safe form of inguinal hernia repair that offers the patient a shorter and less painful recovery with an extremely low recurrence rate.

Laparoscopic inguinal hernia repair: lessons learned after 1224 consecutive cases.

BACKGROUND: Despite numerous attempts to improve the techniques used for hernia repair, current published series show that recurrence rates are as high as 5-20%. The complexity of inguinal anatomy, combined with multiple potential areas of weakness, has contributed to the difficulty in preventing recurrences. However, the laparoscopic approach to inguinal herniorrhaphy has allowed clear visualization of all preperitoneal fascial planes and anatomic landmarks, as well as the hernia defect(s) and the peritoneal reflection. In the course of our performance of a series of 1,224 laparoscopic inguinal hernia repairs, we have developed a total extraperitoneal approach that yields excellent results with a low initial recurrence rate. Herein we describe our experience. METHODS: After our initial 300 transabdominal preperitoneal (TAPP) hernia repairs, which resulted in six recurrences, two bowel injuries, one bladder injury, and six cutaneous nerve injuries, the total extraperitoneal approach (TEP) was adopted. RESULTS: The first 300 TEP repairs resulted in one recurrence, two bowel injuries, one bladder injury, and two cutaneous nerve injuries. All major complications occurred in patients who had had previous lower abdominal surgery. In the last 624 TEP herniorrhaphies we implemented some modifications to the technique, especially for patients with previous lower abdominal surgery. In this group we recorded one bladder injury, no cutaneous nerve injuries, and one recurrence. CONCLUSIONS: The total extraperitoneal approach for laparoscopic herniorrhaphy allows for a safe and effective repair with low rates of complication and recurrence. A thorough knowledge of the anatomy of the extraperitoneal space and especially the two- and three-dimensional inguinal anatomy of this space contributed greatly to the evolution of our technique.

The use of water-soluble contrast in evaluating clinically equivocal small bowel obstruction.

This study seeks to determine whether a 6-hour abdominal radiograph after oral Gastrografin is a reliable indicator for nonoperative treatment in patients with a clinically equivocal small bowel obstruction. We collected retrospective data from medical records. Patients who received a Gastrografin transit time (GGTT) study between January 1995 and September 1998 were included in the study. Patients who did not appear to be obvious operative candidates, but had signs of intestinal obstruction, underwent a GGTT study. Serial plain abdominal radiographs were taken. If the contrast was in the colon within 6 hours, then the result was negative. A total of 418 GGTT studies were reviewed. Contrast reached the colon within 6 hours in 283 (68%) patients, and 247 (88%) of these patients were managed nonoperatively. The positive predictive value, negative predictive value, sensitivity, and specificity of Gastrografin reaching the colon within 6 hours were 48, 87, 64, and 78, respectively. False negatives included high-grade partial obstructions that ultimately required surgery. Recent operation preceded the GGTT in 128 (31%) cases. Of these 128 patients, only 17 (14%) received an operation. Although the decision to operate or not should never be based on a GGTT study alone, GGTT studies are of significant help in the clinical management of patients suspected to have a small bowel obstruction. GGTT allows for the judicious selection of the appropriate patient for nonoperative management. GGTT studies are cost effective, safe, and clinically useful when attempting to treat patients conservatively.

Comparison of laparoscopic and open ventral herniorrhaphy.

The repair of large and/or recurrent ventral hernias is associated with significant complications and a recurrence rate that can be more than 50 per cent. Laparoscopic ventral herniorrhaphy, a recent development, has been shown to be safe and effective in the repair of ventral hernias. This study retrospectively reviews all ventral hernia repairs over a 3-year period, November 1995 through December 1998, at a community-based teaching hospital. The purpose of the study was to compare open and laparoscopic repairs. A total of 253 ventral hernia repairs were performed during this time, 174 open and 79 laparoscopic. The age, weight, and sex distribution was similar for each group. The hernias in the open group averaged 34.1 cm2 in size, and mesh used averaged 47.3 cm2. In the laparoscopic group, the hernia defect averaged 73.0 cm2, and the mesh size averaged 287.4 cm2. Operative time was longer in the open group, 82.0 versus 58.0 minutes. In the open group, there were 38 (21.8%) minor and 8 (4.6%) major complications, compared with 13 (16.5%) minor and 2 (2.5%) major complications in the laparoscopic group. Hospital stay was shorter for the laparoscopic group, 1.7 versus 2.8 days. At an average follow-up of 21 months (range, 2-40 months), there have been 36 recurrences in the open group (20.7%) compared with 2 recurrences in the laparoscopic group (2.5%). In this series, laparoscopic ventral herniorrhaphy compares favorably to open ventral herniorrhaphy with respect to wound complications, hospital stay, operative time, and recurrence rate.

Laparoscopic repair of bilateral and recurrent hernias.

The optimal inguinal hernia repair has been controversial for decades. Since the advent of minimally invasive surgery, laparoscopic techniques have added to the controversy. Laparoscopic hernia repair has been advocated by many experts for the repair of bilateral and recurrent inguinal hernias. This study reviews the experience of a single community-based teaching hospital using the total extraperitoneal (TEP)-approach laparoscopic hernia repair for treating patients with bilateral and/or recurrent inguinal hernias. Since the TEP approach was adopted in June 1993, a total of 457 patients were treated for bilateral (322 patients) and/or recurrent (175) inguinal hernias (40 patients had recurrent and bilateral hernias). A total of 779 hernias were repaired with this technique. The average age of this patient group was 47 years, and there were 413 males and 44 females. Operative time averaged 68.3 minutes per patient, and there were 26 (5.7%) minor complications. There were 2 (0.4%) major complications, an enterotomy and a cystotomy, both early in the series and both in patients with previous lower abdominal surgery. There have been no deaths. With an average follow-up of 30 months (range, 1-60 months), there have been three (0.2%) recurrences. These recurrences were due to technical problems (inadequate mesh coverage), and each was repaired with a laparoscopic transabdominal approach or an anterior open approach. The use of the TEP-approach laparoscopic hernia repair is safe and effective in patients with recurrent and/or bilateral inguinal hernias.

Laparoscopy for diagnosis and staging of malignancy.

The use of minimally invasive surgery for abdominal pathology, including malignancy, has increased significantly within the past decade. Despite the advances in radiographic imaging, the use of laparoscopy for diagnosing and staging abdominal malignancy has become an important tool in the overall care of these patients. A review of published series for a variety of abdominal malignancies is presented. With the growing experience in this technique, some preliminary conclusions and ongoing issues are discussed.

Laparoscopy in the evaluation and treatment of patients with AIDS and acute abdominal complaints.

BACKGROUND: The evaluation of AIDS patients with acute abdominal complaints (AAC) is quite difficult, and surgical intervention is associated with a high complication rate. The intent of this study is to evaluate the application of laparoscopy in the diagnosis and treatment of AIDS patients with AAC. METHODS: This is a retrospective analysis of 10 consecutive AIDS patients who presented with AAC. Each had evaluation by a surgical team with subsequent laparoscopic intervention. The charts were reviewed for age, sex, time with AIDS, AIDS comorbidities, evaluation modalities, findings, treatment modalities, and outcome. RESULTS: Laparoscopy resulted in the successful surgical treatment of four patients, diagnosis of medically treatable conditions in four patients, and alteration of the incision site in the remaining two patients. Each patient thus received direct benefit from laparoscopy. Two complications, in the converted patients, and no mortalities were encountered. CONCLUSIONS: Laparoscopy is a safe and effective interventional modality in the diagnosis and treatment of AAC in the AIDS patient.

500 total extraperitoneal approach laparoscopic herniorrhaphies: a single-institution review.

At Georgia Baptist Medical Center, a community-based, university-affiliated hospital, we adopted the total extraperitoneal approach (TEPA) to laparoscopic herniorrhaphy due to potential complications in entering the abdominal cavity reported previously with the transabdominal preperitoneal technique (Am Surg 1996;62:69-72). We have also employed regional anesthesia (epidural) in 108 patients in whom the TEPA was utilized. In our institution, the TEPA has compared favorably to the transabdominal preperitoneal technique, with lower complication and recurrence rates. In patients with previous lower abdominal surgery, the TEPA is considered a relative contraindication due to the increased risk of complications (Am Surg 1997, in press). Since June 1993, we have performed 503 laparoscopic herniorrhaphies using the TEPA, with encouraging early results. To date, two recurrences have been reported, one with previous lower abdominal surgery and another whose recurrence was noted to be secondary to incomplete reapproximation of the mesh with staples around the cord structures. Four major complications include two bowel perforations and two cystotomies noted during balloon dissection of the preperitoneal space. Three of these patients had previous lower abdominal surgery. Epidural anesthesia was used in 108 patients, 4 of whom required conversion to general anesthesia due to peritoneal tears and pain associated with pneumoperitoneum. All four of these patients had previous lower abdominal surgery. In summary, the TEPA remains a viable technique for laparoscopic herniorrhaphy with acceptable complication and recurrence rates. Epidural anesthesia is well tolerated by the patients undergoing this particular repair. We feel that lower abdominal surgery may be a mitigating factor in selection of the TEPA. Continued re-evaluation of the procedure is warranted before definitive conclusions can be made.

Laparoscopic resection of sigmoid endometrioma.

Endometriosis as a cause for pelvic pain is quite common in women of child-bearing age. However, colonic an rectal involvement is relatively rare and may have a wide array of clinical symptomatology and radiographic findings. We recently treated a patient who presented with constipation and bloating. She was found to have an extrinsic mass compressing the rectosigmoid junction. Subsequent diagnostic laparoscopy revealed a large lesion involving the sigmoid colon, and resection with primary anastomosis was performed using the laparoscope. Final pathology revealed benign endometrioma. The patient did well, was discharged on postoperative Day 3, and has had no further complaints. As this case shows, laparoscopy can be beneficial in both the diagnosis and treatment of patients with intestinal endometriosis.

The effect of previous lower abdominal surgery on performing the total extraperitoneal approach to laparoscopic herniorrhaphy.

At Georgia Baptist Medical Center in Atlanta, GA, we adopted the total extraperitoneal approach (TEPA) to laparoscopic herniorrhaphies because of the concerns of potential early and late complications associated with entering the abdominal cavity. In our institution, the TEPA has compared favorably with the transabdominal approach, with lower complication and recurrence rates. There has been concern, however, in performing the TEPA in patients with previous lower abdominal surgery. The question has been raised that there is increased risk of complications in these patients. From June 1993 to May 1994, we performed 247 laparoscopic herniorrhaphies in 192 patients using the TEPA. Of these, 55 hernias were repaired in 45 patients with previous lower abdominal surgery. Overall retrospective results showed a slightly higher complication rate (23.1% vs 11.3%) and slightly higher recurrence rate (1.8% vs 0%) in the patients with previous surgery over those without. Although these differences are not statistically significant, it is important to keep these risks in mind when selecting the appropriate hernia repair for each patient.

Twenty-year follow-up breast screening project.

Routine yearly breast screening with mammograms and physical examination can usually detect very small nonpalpable cancers that have a high survival rate. Routine breast screening with mammography and physical examination of asymptomatic women is the best method of controlling breast cancer at present.

Technical considerations of the different approaches to laparoscopic herniorrhaphy: an analysis of 500 cases.

Between April 1991 and April 1994, 500 laparoscopic herniorrhaphies have been performed at our institution. The transabdominal preperitoneal approach was used for 290 repairs, and the total extraperitoneal approach was used for 210 repairs. Although both repairs resulted in acceptable recurrence and complication rates, we adopted the total extraperitoneal approach in June 1993, with a resulting lower recurrence rate (0.5% versus 2.1%) and lower complication rate (3.1% versus 11.1%) when compared with the transabdominal approach. In this retrospective review, four epigastric vessel injuries (1.6%) and one bowel obstruction from a port hernia (0.5%) were attributed to the lateral port placement in the transabdominal approach. There were also two visceral injuries (1.0%) from entering the abdominal cavity in the transabdominal approach. The one visceral injury (0.6%) in the total extraperitoneal approach was a result of the balloon dissection in a patient with multiple previous lower abdominal operations. Better exposure and lateral visualization of the extraperitoneal space has led to less incidence of nerve injury (0.0% versus 2.4%) and a lower recurrence rate (0.5% versus 2.1%) in the total extraperitoneal approach. The total extraperitoneal approach to laparoscopic herniorrhaphy compares favorably to the transabdominal approach in our institution. The improved results may have been due to the technical differences between these approaches.

Laparoscopic fundoplication in the treatment of severe gastroesophageal reflux disease: preliminary results of a prospective trial.

To determine the technical feasibility and success of laparoscopic fundoplication in the treatment of severe gastroesophageal reflux disease (GERD), 18 consecutive adult patients were enrolled in a prospective study. All patients had received unsuccessful conservative treatment, were refractory to medical management, or had recurrence of symptoms of esophagitis after omeprazole therapy. All patients had severe acid reflux on 24-hour esophageal pH monitoring, endoscopic evidence of previous or ongoing esophagitis, and a defective lower esophageal sphincter on manometry. Complete (Nissen) fundoplication was done in 11 and partial (Toupet) fundoplication in 7 patients; the mean operative time was 183 minutes (range, 120 to 357 minutes). Feedings were initiated on the first postoperative day, and the average length of stay was 2.6 days (range, 1 to 6). There were no deaths or conversions to laparotomy. Postoperative morbidity consisted of transient bloating in three patients and dysphagia requiring dilatation in four patients. Return to work or normal activity averaged 19 days (range, 3 to 28), and 17 patients (94%) reported good to excellent results, with a median follow-up of 7 months. Laparoscopic fundoplication is technically feasible and offers a sound surgical alternative to patients with refractory GERD, but longitudinal follow-up is required to confirm long-term results.

A comparison of the approaches to laparoscopic herniorrhaphy.

BACKGROUND: There are a variety of accepted techniques for herniorrhaphy. With the advent of laparoscopic general surgery, new endoscopic techniques using the transabdominal and total extraperitoneal approaches have been added to the many options for the repair of inguinal hernia. The purpose of this study was to compare the early results of these approaches at a single institution. METHODS: Between May 1991 and August 1994, 600 laparoscopic herniorrhaphies were performed on 493 patients. Three hundred hernias were repaired using the transabdominal preperitoneal approach and 300 were repaired using the total extraperitoneal approach. A retrospective review was performed with emphasis on the comparison of recurrence rates and complication rates between these two approaches to laparoscopic herniorrhaphy. RESULTS: The recurrence rates were 2.0% (6/300) for the transabdominal approach and 0.3% (1/300) for the total extraperitoneal approach. The complication rate for the transabdominal approach was 10.7% and included thigh paresthesias (6), inferior epigastric artery injuries (4), enterotomy (1), bowel obstruction (1), bladder injury (1), and urinary retention (14). The complication rate for the total extraperitoneal approach was 3.7% and included enterotomies (2), bladder injury (1), paresthesia (1), and urinary retention (6). The recurrence, the enterotomies, and the bladder injury in the total extraperitoneal group were all in patients who had previous lower abdominal operations. CONCLUSIONS: Although both the transabdominal preperitoneal and total extraperitoneal approaches to laparoscopic herniorrhaphy have acceptable recurrence and complication rates, there were significant advantages to the total extraperitoneal approach in our institution. Previous lower abdominal surgery may be a relative contraindication to the total extraperitoneal approach.

Twenty-year review of a breast cancer screening project. Ninety-five percent survival of patients with nonpalpable cancers.

BACKGROUND: In 1973, the Breast Cancer Detection Demonstration Project at the Georgia Baptist Medical Center began screening supposedly asymptomatic women for breast cancer. The project has been reviewed and now 20 years later, the follow-up of those women with detected cancer who were matched with a group of the original cohort with negative screens is reported. Early criticism of the project was its "lead-time bias," which, after 20 years, should pose no problem. METHODS: Approximately 9043 women were screened for 5 years. The remainder of the total of 10,000 women were screened at the Emory University Department of Radiology. The 128 patients who were found to have breast cancer were observed for over 20 years. A matched group of 1609, who had negative results when originally screened, were also observed for 20 years. RESULTS: After 20 years, approximately 86% of the 128 women diagnosed with breast cancer were still free of disease, including 88.3% of women with lesions of less than 1.1 cm and 95.1% of those with nonpalpable carcinomas. CONCLUSIONS: Over 95% of the 67 women with nonpalpable lesions were alive after 20 years of follow-up. Women not screened yearly tend to have larger lesions than those screened on a regular basis. Regular screening is currently the best way to control this disease.

1525 laparoscopic cholecystectomies without biliary injury: a single institution's experience.

Laparoscopic Cholecystectomy (LC) has become the preferred treatment of gallbladder disease. The indications for LC remain unchanged from those for open cholecystectomy (OC). A total of 1525 patients underwent LC at Georgia Baptist Medical Center between December 1989 and December 1992. The procedure was completed in 1,492 patients (97.8%) and required conversion to OC in 33 patients (2.2%). Selective intraoperative cholangiography was used in 165 patients (10.8%). Overall morbidity was 4.06%, and there were four deaths not operatively related, for a 0.26% mortality rate. There have been no biliary ductal injuries. The average hospital stay was 0.82 days, with 37.4% of the patients going home as true outpatients and 44.5% going home on postop Day one. Most published series on LC report a small incidence of biliary injury. We feel that with meticulous dissection of the cystic duct and use of selective intraoperative cholangiography to define unsure anatomy, biliary injury can be minimized.

A comparison of transabdominal preperitoneal (TAPP) and total extraperitoneal approach (TEPA) laparoscopic herniorrhaphies.

There are a variety of accepted techniques for herniorrhaphy. With the advent of laparoscopic general surgery, laparoscopic transabdominal and total extraperitoneal techniques have been added to the many options for repair of the inguinal hernia. From 5/91 to 6/93 we had performed 290 transabdominal preperitoneal (TAPP) laparoscopic herniorrhaphies on 244 adult patients. Due to concerns of potential early and late complications associated with entering the abdominal cavity, we adopted the total extraperitoneal approach (TEPA) for laparoscopic herniorrhaphies in 6/93. Between 6/93 and 12/93, 118 hernias have been repaired in 95 patients using the total extraperitoneal approach. In a retrospective comparison between these two procedures, the recurrence rate is 1.7% (5/290) for TAPP herniorrhaphies and 0% (0/118) for the TEPA. The overall complication rate for TAPP herniorrhaphies was 11.1% and included thigh paresthesias (6), inferior epigastric artery injuries (4), enterotomy (1), bowel obstruction (1), bladder injury (1), and urinary retention (14). The overall complication rate for the TEPA was 3.2% and included bladder injury (1), and urinary retention (2). Mean operative time was similar between these groups (TAPP-81.2 minutes, TEPA-92.9 minutes).

Laparoscopically assisted bowel surgery. Analysis of 114 cases.

In order to help determine the risks and benefits, we retrospectively analyzed the results of our first 114 laparoscopically assisted bowel procedures. Procedures performed consisted of partial colectomy (85), total or subtotal abdominal colectomy (8), total proctocolectomy with J-pouch ileal reservoir (11), and diverting procedures (10). Forty-nine procedures were for malignancy. The rate of conversion to laparotomy was 13.2%. Oral feedings were resumed in 2.4 days (range 1-5), and bowel function returned in 3.8 days (range 2-8). The average length of stay was 4.2 days for partial colectomy and 6 days for total, subtotal, and proctocolectomy. The mean return to normal activity for all groups was 16.7 days (10.8 days for partial colectomy). There were no deaths. Major morbidity (6%) consisted of abscess (3), anastomotic leak (2), and hemorrhage (1). Mean operative costs analyzed for the initial 37 patients were higher for laparoscopic colectomies when compared to traditional colectomies; however, the mean total hospital costs were less for the laparoscopic procedures. These data suggest that the laparoscopic approach to colorectal resection is an acceptable alternative to laparotomy for a variety of disease processes, allowing patients an early return to normal activity.

Diagnostic laparoscopy for suspected appendicitis.

One hundred consecutive patients who underwent diagnostic laparoscopy for suspected appendicitis were evaluated to assess the appropriate clinical setting for laparoscopic appendectomy. The usefulness of diagnostic laparoscopy in the setting of acute abdominal pain has been well documented. However, there is debate about the use of laparoscopy for definitive therapy. The purpose of this study is to evaluate the decision making process during diagnostic laparoscopy for suspected appendicitis. When pathology is identified other than in the appendix, the majority of patients can be treated without converting to an open procedure. In patients found to have no obvious pathology, incidental appendectomy can be performed laparoscopically. When appendicitis was identified, the majority of patients could be treated safely without converting to an open technique. However, there were certain clinical situations that necessitated conversion to an open operation. Involvement of the cecum or perforation at the base of the appendix puts the appendiceal stump at risk for leak and abscess formation. Evaluation of the cecum by palpation for a mass should also be performed in this situation. Another situation in which conversion to an open technique is warranted is an appendiceal abscess with adherent small bowel. The friability of bowel wall greatly increases the risk for bowel injury in this setting. Laparoscopy is a useful technique for the diagnosis and treatment of abdominal pain even if the appendix is normal on inspection. Conversion to an open operation should be employed when inflammation or perforation occurs at the base of the appendix and when bowel is found to be adherent to an appendiceal abscess.