Treatment of haemorrhoids: rubber band ligation or sclerotherapy (THROS)? Study protocol for a multicentre, non-inferiority, randomised controlled trial.

INTRODUCTION: Haemorrhoidal disease (HD) is a common condition with significant epidemiologic and economic implications. While it is possible to treat symptomatic grade 1-2 haemorrhoids with rubber band ligation (RBL) or sclerotherapy (SCL), the effectiveness of these treatments compatible with current standards has not yet been investigated with a randomised controlled trial. The hypothesis is that SCL is not inferior to RBL in terms of symptom reduction (patient-related outcome measures (PROMs)), patient experience, complications or recurrence rate. METHODS AND ANALYSIS: This protocol describes the methodology of a non-inferiority, multicentre, randomised controlled trial comparing rubber band ligation and sclerotherapy for symptomatic grade 1-2 haemorrhoids in adults (> 18 years). Patients are preferably randomised between the two treatment arms. However, patients with a strong preference for one of the treatments and refuse randomisation are eligible for the registration arm. Patients either receive 4 cc Aethoxysklerol 3% SCL or 3 × RBL. The primary outcome measures are symptom reduction by means of PROMs, recurrence and complication rates. Secondary outcome measures are patient experience, number of treatments and days of sick leave from work. Data are collected at 4 different time points. DISCUSSION: The THROS trial is the first large multicentre randomised trial to study the difference in effectivity between RBL and SCL for the treatment of grade 1-2 HD. It will provide information as to which treatment method (RBL or SCL) is the most effective, gives fewer complications and is experienced by the patient as the best option. ETHICS AND DISSEMINATION: The study protocol has been approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centers, location AMC (nr. 2020_053). The gathered data and results will be submitted for publication in peer-reviewed journals and spread to coloproctological associations and guidelines. TRIAL REGISTRATION: Dutch Trial Register NL8377 . Registered on 12-02-2020.

To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry, and transperineal ultrasound.

BACKGROUND: Anorectal function tests are helpful for objective investigation of anorectal (dys)function. A variety of tests are available, but there is no recommendation when to perform which test. Furthermore, which test is the most accurate is controversial and the correlation between these tests is not very clear. The aim of our study was to examine the correlation of anal pressures and the possibility to diagnose pelvic floor dyssynergia between digital rectal examination (DRE) and several anorectal function tests. METHODS: Between January 2020 and April 2022, all men and women aged 18 to 80 years, treated at the Proctos Clinic, who were referred for pelvic floor physical therapy (PFPT) by the surgeon and underwent anorectal function tests, were included. DRE was performed to establish the anal pressure at rest and during squeeze and straining. Anorectal function tests included 3D high-resolution anal manometry (3D-HRAM), balloon expulsion test (BET), transperineal ultrasound (TPUS), and surface electromyography (s-EMG). RESULTS: A total of 50 patients, 37 (74%) females, were included. Median age was 51 years. Twenty-three (62%) females had a history of two or more vaginal deliveries. The most frequent reason for referral for PFPT was fecal incontinence in 27 (54%) patients. The assessed pressures and pelvic floor function measured with DRE by the surgeon and the pelvic floor physical therapist during rest, squeeze, and straining correlated in 78%, 78%, and 84%, respectively. Correlation between DRE and 3D-HRAM or s-EMG was better for squeeze pressures than resting pressures. The correlation between s-EMG and 3D-HRAM was better during squeeze than at rest with an agreement of 59% and 37%, respectively. CONCLUSION: DRE by an experienced investigator is of sufficient value for daily clinical practice to detect dyssynergia and to measure sphincter tone. Commonly performed anorectal function tests correlate poorly with DRE and with other anorectal function tests. When conservative treatment fails, further investigation is warranted; however, these results should be interpreted with caution. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: Anorectal function tests such as the 3D high-resolution anorectal manometry, balloon expulsion test, surface electromyography, and transperineal ultrasound are all frequently performed in the diagnostic workup in patients with defecation disorders. No previous study has compared these tests regarding their outcomes, nor has the interrater agreement been measured regarding the digital rectal examination by two experienced observers. Furthermore, transperineal ultrasound is in all probability not frequently used and therefore underexposed in the diagnostic workup of patients with dyssynergic defecation.

Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF trial): quality of life outcome.

BACKGROUND: Chronic anal fissure is one of the most common anorectal diseases and is associated with reduced quality of life. The aim of this study was to investigate the effects of pelvic floor physical therapy on quality of life in patients with chronic anal fissure using the Short-Form 36 Health Survey (RAND-36). METHODS: Adult patients, with chronic anal fissure and concomitant pelvic floor dysfunction, such as dyssynergia and increased pelvic floor muscle tone, were recruited at the Proctos Clinic in the Netherlands, between December 2018 and July 2021 and randomly assigned to an intervention group, receiving 8 weeks of pelvic floor physical therapy or assigned to a control group receiving postponed pelvic floor physical therapy (PAF trial). Quality of life and pain ratings were outcomes of the study and were measured at 8- and 20-week follow-up. RESULTS: One hundred patients (50 women and 50 men, median age 44.6 years [range 19-68 years]), completed the RAND-36 questionnaire and visual analog (VAS) pain scale score at admission. A significant improvement was found at 20-week follow-up in all domains of the RAND-36; physical functioning, pain, health change (p < 0.001); physical role, vitality, general health, social functioning, emotional role, mental health (p < 0.05). VAS pain was significantly reduced at 8 weeks (mean estimated difference 1.98; 95% CI 1.55-2.42, p < 0.001) and remained significant at 20-week follow-up (p < 0.001). The difference between the groups as regards change in the mean pain intensity scores at 8 weeks was 2.48 (95% CI - 3.20 to - 1.75; p < 0.001). Compared to the reference values of the general Dutch population, the patients in our study with a chronic anal fissure and pelvic floor dysfunction reported an impaired quality of life in 8 of 9 domains of the RAND-36. After treatment, significant lower scores were found in 2 out of 9 domains. CONCLUSIONS: The results of this study provide evidence that treatment by pelvic floor physical therapy improves quality of life and reduces pain, making it an important tool in management of chronic anal fissure and concomitant pelvic floor dysfunction.

Is the Goligher classification a valid tool in clinical practice and research for hemorrhoidal disease?

BACKGROUND: The most widely used classification for hemorrhoidal disease (HD) is the Goligher classification, which ranks presence and severity of prolapse in four grades. Since physicians base this gradation on medical history and physical examination, it might be prone to interobserver variability. Furthermore, the gradation impacts the treatment of choice which makes reproducibility of utmost importance. The aim of this study was to determine the interobserver variability of Goligher classification among surgeons in the Netherlands. METHODS: A single-choice survey was used. The first part consisted of questions concerning baseline characteristics and the use of the Goligher classification in routine clinical practice. In the second part, to assess interobserver variability, we asked gastrointestinal surgeons and residents who routinely treat HD to review 25 photographs (with given timing as during rest or push) of patients with HD and classify the gradation using the Goligher classification. The survey was sent by email on April 19, 2021 and was available online until July 5, 2021. Interobserver variability was assessed using Fleiss' Kappa test. RESULTS: A total of 329 gastrointestinal surgeons, fellows and residents were sent an invitation email, of whom 95 (29%) completed the survey. Among the respondents, 87% indicated that they use the Goligher classification in clinical practice. Eighty-one percent found the classification helpful and 63% classified HD according to Goligher and followed the guidelines for treatment of HD accordingly. The interobserver variability showed an overall fair strength of agreement, with a Fleiss' Kappa (κ) of 0.376 (95% CI 0.373-0.380). There was a moderate agreement for grade I and IV HD with a κ statistic of 0.466 and 0.522, respectively. For grades II and III, there was a lower (fair) strength of agreement with 0.206 and 0.378, respectively. CONCLUSIONS: The fair interobserver variability is disappointing and demonstrates the need for a more reliable, and internationally accepted, classification for HD. A new classification should enable more uniformity in treating HD and in comparing outcomes of future trials and prospective registries. The protocol for a Delphi study for a new classification system is currently being prepared and led by an international research group.

Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands.

BACKGROUND: Management of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands. METHODS: Dutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA. RESULTS: In total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%). CONCLUSIONS: Dutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.

Rubber band ligation versus haemorrhoidectomy for the treatment of grade II-III haemorrhoids: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: The aim of this study was to review clinical outcome of haemorrhoidectomy and rubber band ligation in grade II-III haemorrhoids. METHODS: A systematic review was conducted. Medline, Embase, Cochrane Library, Clinicaltrials.gov, and the WHO International Trial Registry Platform were searched, from inception until May 2018, to identify randomised clinical trials comparing rubber band ligation with haemorrhoidectomy for grade II-III haemorrhoids. The primary outcome was control of symptoms. Secondary outcomes included postoperative pain, postoperative complications, anal continence, patient satisfaction, quality of life and healthcare costs were assessed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: Three hundred and twenty-four studies were identified. Eight trials met the inclusion criteria. All trials were of moderate methodological quality. Outcome measures were diverse and not clearly defined. Control of symptoms was better following haemorrhoidectomy. Patients had less pain after rubber band ligation. There were more complications (bleeding, urinary retention, anal incontinence/stenosis) in the haemorrhoidectomy group. Patient satisfaction was equal in both groups. There were no data on quality of life and healthcare costs except that in one study patients resumed work more early after rubber band ligation. CONCLUSIONS: Haemorrhoidectomy seems to provide better symptom control but at the cost of more pain and complications. However, due to the poor quality of the studies analysed/it is not possible to determine which of the two procedures provides the best treatment for grade II-III haemorrhoids. Further studies focusing on clearly defined outcome measurements taking patients perspective and economic impact into consideration are required.

Botox treatment in patients with chronic functional anorectal pain: experiences of a tertiary referral proctology clinic.

BACKGROUND: Anorectal pain is a symptom which may have both structural and functional causes, and can, sometimes, develop into a chronic pain syndrome. Functional causes in particular are challenging to treat when conservative treatment measures fail. Botulinum toxin A (BTX-A) can be applied to relax the anal sphincter and/or levator ani muscle to break the vicious circle of pain and contraction. In our tertiary referral proctology clinic, we evaluated the outcome of patients treated with BTX-A for chronic functional anorectal pain. METHODS: Our electronic database was searched for patients who had BTX-A treatment for chronic functional anorectal pain from 2011 to 2016. All medical data concerning history, treatments, and clinical outcome were retrieved. The clinical outcome (resolution of pain) was scored as good, temporary, or poor. RESULTS: A total of 113 patients [47 (42%) males; age 51years, SD 13 years, range 18-88 years] with chronic functional anorectal pain were included. The outcome of BTX-A treatment was good in 53 (47%), temporary in 23 (20%), and poor in 37 (33%). To achieve this outcome, 29 (45%) patients needed a single treatment, 11 (44%) a second treatment, and 13 (54%) ≥ 3 treatments. CONCLUSIONS: Chronic functional anorectal pain can be treated successfully with BTX-A in 47% of patients who fail conservative management. Repeated injections may be needed to ensure complete cure in a subgroup of patients.

Morphological adaptation of rumen papillae during the dry period and early lactation as affected by rate of increase of concentrate allowance.

Knowledge of the morphological adaptation of rumen papilla, which plays an important role in volatile fatty acid absorption, in dry and early lactation dairy cattle is limited. Therefore, macro- and microscopic changes in papilla morphology during the dry period and lactation and the effect of rate of increase of concentrate allowance were studied. Samples were collected from 12 rumen-cannulated Holstein Friesian dairy cows during a pretreatment period, 50, 30, and 10 d antepartum (the dry period) and 3 d postpartum (pp), and a treatment period, 9, 16, 30, 44, 60, and 80 d pp. Cows had free access to either a dry period ration [27% grass silage, 27% corn silage, 35% wheat straw, and 11% soybean meal on a dry matter (DM) basis] or a basal lactation ration (42% grass silage, 41% corn silage, and 17% soybean meal on a DM basis, and 0.9 kg of DM/d concentrate). Treatment consisted of either a rapid (1.0 kg of DM/d; RAP; n=6) or gradual (0.25 kg of DM/d; GRAD; n=6) increase of concentrate allowance (up to 10.9 kg of DM/d), starting at d 4 pp, aimed at creating a contrast in rumen-fermentable organic matter (FOM) intake. Papillae were collected from the ventral, ventral blind, and dorsal blind rumen sacs and measured digitally. Intake of DM (11.9 kg/d) and FOM (5.7 kg/d) did not change during the pretreatment period, but increased during the treatment period to 24.5 and 15.0 kg/d at 80 d pp, respectively. Concentrate treatment and sampling day interacted for FOM intake, which was 22% greater in RAP at 16 d pp compared with GRAD. Papilla surface area decreased during the pretreatment period by 19% to 28.0mm(2) at 3 d pp, thereafter increasing to 63.0mm(2) at 80 d pp. Concentrate treatment and sampling day interacted for surface area, which was greater in RAP compared with GRAD at 16 (46.0 vs. 33.2mm(2)), 30 (55.4 vs. 41.2mm(2)), and 44 (60.5 vs. 49.7 mm(2)) days pp, showing that papillae can respond to a rapid rate of increase of FOM intake by increasing growth rate. Microscopic morphology was affected by sampling day, but neither by concentrate treatment nor by their interaction, with a decrease in papilla and epithelium thickness during the lactation. In conclusion, the rumen papillae respond to changes in FOM intake and the magnitude of this response depends on the rate of increase of FOM intake. This response in surface area of the rumen papillae potentially facilitates the absorption of the volatile fatty acids.

Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery.

BACKGROUND: Postoperative convalescence is mainly determined by the extent and duration of postoperative ileus. This randomized clinical trial evaluated the effects of early oral feeding on functional gastrointestinal recovery and quality of life. METHODS: One hundred and twenty-eight patients undergoing elective open colorectal or abdominal vascular surgery participated in the trial. Of these, 67 were randomized to a conventional return to diet, and 61 to a regimen allowing resumption of an oral diet as soon as tolerated (free diet group). RESULTS: Reinsertion of a nasogastric tube was necessary in 20 per cent of the free diet group and 10 per cent of the conventional group (P = 0.213). The complication rate was similar for both groups, as was return of gastrointestinal function. A normal diet was tolerated after a median of 2 days in the free diet group compared with 5 days in the conventional group (P < 0.001). Quality of life scores were similar in both groups. CONCLUSION: Early resumption of oral intake does not diminish the duration of postoperative ileus or lead to a significantly increased rate of nasogastric tube reinsertion. Tolerance of oral diet is not influenced by gastrointestinal functional recovery. As there is no reason to withhold oral intake following open colorectal or abdominal vascular surgery, postoperative management should include early resumption of diet.

Randomized clinical trial comparing feeding jejunostomy with nasoduodenal tube placement in patients undergoing oesophagectomy.

BACKGROUND: Feeding jejunostomy is frequently performed in patients undergoing oesophageal surgery, but can lead to serious complications. This prospective randomized trial compared the efficacy and complications of feeding jejunostomy with those of nasoduodenal tube feeding in oesophageal surgery. METHODS: Over an 18-month period, 150 consecutive patients undergoing oesophageal resection were randomized to participate in the trial. Enteral access was by jejunostomy in 79 patients and by nasoduodenal tube in 71. Enteral feeding was started on the first day after surgery. RESULTS: Full enteral feeding took 3 days to be established in both groups. Minor catheter-related complications occurred in 28 patients (35 per cent) in the jejunostomy group, and in 21 (30 per cent) in the nasoduodenal group (P = 0.488). One patient had jejunostomy leakage that required reoperation. Enteral nutrition was given for a median of 11 days in the jejunostomy group and for 10 days in the nasoduodenal group. Nine patients who had a jejunostomy and five with a nasoduodenal tube did not tolerate full enteral feeding (P = 0.411). CONCLUSION: Nasoduodenal tube feeding is safe and efficient after oesophageal resection.

Nutritional status as a risk factor in esophageal surgery.

BACKGROUND: Nutritional condition is one of the factors determining postoperative outcome in esophageal surgery. This study explored the relation between preoperative nutritional status and postoperative infectious complications. METHODS: From a prospective database, 400 patients who underwent esophageal resection for malignancy were selected. Preoperative nutritional status was assessed by body mass index, prognostic nutritional index (PNI), nutritional risk index (NRI) and weight loss. The association between nutritional parameters and postoperative complications and mortality, gender, age and hospitalization was assessed. RESULTS: PNI and NRI differed between the patients with and without postoperative infectious complications (p = 0.031 and p = 0.009, respectively). However, receiver operating characteristic curves showed that PNI and NRI have a low predictive value for such complications. Also, no associations were found between nutritional parameters and in-hospital mortality. Although mean nutritional parameters were significantly lower, i.e. worse, in patients with neoadjuvant treatment as compared to no such treatment, the incidence of complications did not significantly differ between these treatment groups. Although PNI and NRI correlated negatively with age, no association was found between age and infectious complications. Multivariate analysis of various factors showed the male gender to be the only significant risk factor for development of infectious complications. DISCUSSION: Preoperative nutritional status established by PNI, NRI, body mass index and weight loss has limited value in predicting complications following esophageal resection.

Aggressive angiomyxoma: multimodality treatments can avoid mutilating surgery.

AIMS: Aggressive angiomyxoma is a soft-tissue tumour of the pelvi-perineum. The recurrence rate is high, and often extensive resections are performed with considerable morbidity. In search of alternative treatment methods we present our experience in seven patients. METHODS: The medical charts of seven patients treated in the last 20years were reviewed. Follow-up data were obtained. In addition, a literature review from 1994 to 2004 regarding treatment and clinical outcome was performed. RESULTS: All patients were female, and three were pregnant at the time of diagnosis. All patients underwent primary surgical treatment. In five patients the surgical margins were involved; one patient received adjuvant radiotherapy treatment. Three patients experienced a total of four recurrences after 2-10years. These patients were treated with selective embolisation or surgery. At present all patients are disease-free, with follow-up ranging from 2 to 20years after last treatment. CONCLUSION: Radical surgery does not seem to lead to a significant lower recurrence rate of aggressive angiomyxoma when compared to incomplete resection (R1), with or without radiotherapy or arterial embolisation. This casts doubt on the necessity of extensive surgery, especially in cases where an extensive surgical procedure will lead to great morbidity.

Laparoscopic feeding jejunostomy: a systematic review.

BACKGROUND: Enteral feeding devices have gained popularity since the beneficial effects of enteral nutrition have been clarified. Laparoscopic placement of a feeding jejunostomy is the most recently described enteric access route. In order to classify current surgical techniques and assess evidence on safety of laparoscopic feeding jejunostomy, a systematic review was performed. METHODS: The electronic databases Medline, Cochrane, and Embase were searched. Reference lists were checked and requests for additional or unpublished data were sent to authors. Outcome measures were surgical technique and catheter-related complications. RESULTS: Enteral access for feeding purposes can be effectively achieved by laparoscopic jejunostomy. Laparoscopic jejunostomy can be accomplished by either total laparoscopic or laparoscopic-aided techniques. The most experience was obtained with total laparoscopic placement. Which technique to apply should depend on the surgeon's expertise. Conversion rate is similar to other laparoscopic procedures. Complications can be serious and therefore strict patient selection should be warranted. CONCLUSION: Laparoscopic feeding jejunostomy is a viable method to obtain enteral access with the advantages of minimally invasive surgery.

Randomized clinical trial of patient-controlled versus fixed regimen feeding after elective abdominal surgery.

BACKGROUND: Although studies have shown that early oral feeding after abdominal surgery is feasible, many surgeons still advocate a careful, slow introduction of postoperative oral feeding. This study was conducted to investigate whether patient-controlled postoperative feeding is possible in patients undergoing colonic or aortic surgery. METHODS: A randomized clinical trial compared patient-controlled postoperative oral feeding (PC group) with a fixed regimen (FR group). Patients in the PC group (n = 56) received oral feeding when they requested it; patients in the FR group (n = 49) started a normal diet on day 5. Endpoints were time to tolerance of a diet similar to the preoperative diet, reinsertion of a nasogastric tube, complications and duration of hospitalization. RESULTS: Median time to resumption of a normal diet was 3 days in the PC group and 5 days in the FR group (P < 0.001). Reinsertion of a nasogastric tube was required in nine patients in each group (P not significant). The incidence of complications was similar in both groups: 12 of 56 in the PC group and 13 of 49 in the FR group. There was no significant difference in duration of hospital stay between the groups. CONCLUSION: Most patients tolerate a normal diet on the third day after operation. Patient-controlled postoperative feeding is safe and leads to earlier resumption of a normal diet.

Risk factors for inguinal hernia in women: a case-control study. The Coala Trial Group.

Potential risk factors for inguinal hernia in women were investigated and the relative importance of these factors was quantified. In women, symptomatic but nonpalpable hernias often remain undiagnosed. However, knowledge on this subject only concerns hernia and operation characteristics, which have been obtained by review of case series. Virtually nothing is known about risk factors for inguinal hernia. The authors performed a hospital-based case-control study of 89 female patients with an incident inguinal hernia and 176 age-matched female controls. Activity since birth with two validated questionnaires was measured and smoking habits, medical and operation history, Quetelet index (kg/m2), and history of pregnancies and deliveries were recorded. Response for cases was 81% and for controls 73%. Total physical activity was not associated with inguinal hernia (univariate odds ratio (OR) = 0.8, 95% confidence interval (CI) 0.6-1.1), but high present sports activities was associated with less inguinal hernia (multivariate OR = 0.2, 95% CI 0.1-0.7). Obesity (Quetelet index > 30) was also protective for inguinal hernia (OR = 0.2, 95% CI 0.04-1.0). Independent risk factors were positive family history (OR = 4.3, 95% CI 1.9-9.7) and obstipation (OR = 2.5, 95% CI 1.0-6.7). In particular, smoking, appendectomy, other abdominal operations, and multiple deliveries were not associated with inguinal hernia in females. The protective effect of present sports activity may be explained by optimizing the resistance of the abdominal musculature protecting the relatively small inguinal weak spot in the female. The individual predisposition for inguinal hernia may be quantified by these risk factors, and, with this in mind, the authors advise that further evaluation might be needed for the patient with unexplained inguinal pain.

A randomized comparison of physical performance following laparoscopic and open inguinal hernia repair. The Coala Trial Group.

BACKGROUND: Return to normal activity after laparoscopic inguinal hernia repair has been reported to occur sooner than after conventional repair. METHODS: As part of a randomized study, the ability of patients to return to normal activity was assessed by measuring abdominal muscular performance with an exercise test. In addition, patients completed a questionnaire concerning activities of daily life (ADL) and were asked when they returned to normal activities. All patients were given similar instructions for resumption of activities. RESULTS: Patients who had a laparoscopic repair returned to normal activities sooner (6 versus 10 days; P = 0.0003). One week after operation, these patients were able to perform more repetitions of both exercise (14 versus two straight leg raises; 16 versus seven curled sit ups; both P < 0.0001) and their ADL scores were significantly better (89 versus 72; P = 0.0001). CONCLUSION: Laparoscopic hernia repair results in a quicker recovery.