Single-port versus multi-port totally extraperitoneal (TEP) inguinal hernia repair: A meta-analysis of randomized controlled trials.

BACKGROUND: The value of single-port totally extraperitoneal inguinal hernia repair (STEP) when compared to the conventional multi-port approach (TEP) is still a matter of controversy. We conducted a meta-analysis of randomized controlled trials comparing the feasibility and safety of the above-mentioned techniques. METHODS: A systematic literature search for randomized controlled trials (RCTs) comparing the outcome STEP and TEP in patients with inguinal hernia was conducted. Data regarding postoperative outcomes were extracted and compared by meta-analysis. The Odds Ratio and Standardized Mean Differences with 95% Confidence Intervals (CI) were calculated. RESULTS: Six RCTs were identified, involving a total of 636 cases (STEP: n = 328, TEP: n = 308). There was a statistically significant difference noted between the 2 groups regarding return to everyday activities favoring the STEP group (SMD = -0.23; 95% CI [-0.41, -0.06]; P = .01; 4 studies; I2 = 9). For the remaining primary and secondary endpoints, intra- and postoperative morbidity, conversion rate, peritoneal tears, major intraoperative bleeding, postoperative haematoseroma, operative time, postoperative pain, chronic pain, cosmetic satisfaction, hernia recurrence and in-hospital length of stay no statistically significant difference was noted between the 2 study groups. CONCLUSIONS: Current evidence suggests that patients who underwent STEP had similar outcomes to the traditional TEP technique with the exception of time to return to everyday activities, which was reported to be shorter in the STEP group.

Effect of Previous Lower Abdominal Surgery on Outcomes Following Totally Extraperitoneal (TEP) Inguinal Hernia Repair.

BACKGROUND: Previous lower abdominal surgery is generally considered as a relative contraindication for laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. Our objective was to investigate the feasibility and safety of TEP repair in patients with a history of lower abdominal surgery. MATERIALS AND METHODS: A retrospective analysis of 301 patients with inguinal hernia who underwent elective laparoscopic TEP repair between August 2010 and August 2014 was conducted. One-hundred five patients (34.9%) had previously undergone lower abdominal surgery. The main outcome measures included intraoperative and postoperative morbidity and mortality. Secondary outcomes were immediate postoperative pain, presence of chronic pain at follow-up, and hernia recurrence. RESULTS: Patient demographics and clinical variables were balanced between the 2 groups, with the exception of age. Intraoperative morbidity was similar between cases without previous lower abdominal surgery (nPS) and cases with history of lower abdominal surgery (PS) [nPS vs. PS: 0.5% (n=1) vs. 2.8% (n=3), P=0.09]. Overall 30-day morbidity was found to be significantly higher in the PS patient group [nPS vs. PS: 1.5% (n=3) vs. 6.6% (n=7), P=0.018]. Mortality was nil. There were no differences noted between the 2 groups with respect to early postoperative pain and chronic inguinal pain. Complete follow-up information was available for 149 of 301 patients (follow-up rate of 49.5%, range: 3 to 48 mo) with a mean follow-up time of 20.38 months (SD=7.7). There was no statistically significant difference noted in the recurrence rate between the 2 patient groups at follow-up [nPS vs. PS: 3.2% (n=3) vs. 1.8% (n=1), P=0.6]. CONCLUSIONS: The present work demonstrates higher incidence of postoperative scrotal hematoma after TEP repair in patients with history of previous lower abdominal surgery. All remaining outcomes of interest were found to be similar between the 2 patient groups. Further trials will be needed to verify our findings.

Karydakis flap reconstruction versus Limberg flap transposition for pilonidal sinus disease: a meta-analysis of randomized controlled trials.

INTRODUCTION: The definitive treatment of pilonidal sinus disease (PSD) is surgical. There is still no consensus as to the most appropriate off-midline primary closure technique. The aim of this meta-analysis has been to compare Karydakis flap reconstruction (KF) to Limberg flap transposition (LF) with regard to short- and long-term postoperative outcomes. METHODS: A systematic literature search for randomized controlled trials (RCTs) comparing KF to LF was performed. Data regarding postoperative outcomes were extracted and compared by meta-analysis. The odds ratio and standardized mean differences with 95% confidence intervals (CIs) were calculated. RESULTS: Eight RCTs were identified comparing KF (n = 554) to LF (n = 567). There was no significant difference noted between KF and LF with regard to the primary outcome variable, recurrence rate (OR = 1.07; 95% CI [0.59-1.92]; p = 0.83; 7 studies; I2 = 40%). LF was associated with a lower rate of post-operative seroma (OR = 2.03; 95% CI [1.15, 3.59]; p = 0.01; 7 studies; I2 = 0%). No further significant differences were noted in the secondary endpoints between the two study groups. CONCLUSIONS: Recurrence rates of PSD were found to be similar in both study groups. Post-operative seroma rate was significantly higher in the KF group. The meta-analysis did not indicate any further statistically significant differences between the two surgical procedures.

Reversal of Diverting Loop Ileostomy Using Hand-Sewn Side-to-Side versus End-to-End Anastomosis after Low Anterior Resection for Rectal Cancer: A Single Center Experience.

Construction of diverting loop ileostomy has become a common adjunct to low anterior resection for rectal cancer because it substantially reduces the severity of postoperative morbidity. Various trials have compared hand-sewn with stapled anastomotic techniques, but the existing evidence regarding different configurations of hand-sewn anastomoses is scarce. The aim of this study is to compare the early postoperative outcomes of loop ileostomy reversal using the hand-sewn end-to-end or side-to-side configuration. A retrospective review was conducted on 62 consecutive patients undergoing ileostomy reversal between January 2012 and June 2017. The main outcome measure was postoperative bowel obstruction within 30 days after ileostomy reversal. Secondary outcomes included rate of anastomotic insufficiency, wound infection, reoperation, postoperative length of stay, and overall morbidity. The end-to-end (EE) anastomosis group consisted of 32 cases, whereas the side-to-side (SS) group consisted of 30 cases. Patient demographics, comorbidities, and BMI were similar between the two groups. No statistically significant difference was noted regarding postoperative bowel obstruction between the two groups [EE vs SS: 4/32 vs 0, P = 0.11]. Postoperative length of stay was longer for the EE group (P = 0.03). Overall, 30-days morbidity was higher for the EE group (EE vs SS: 11/32 vs 3/30, P = 0.03). All other secondary outcomes did not differ between the two groups. No statistically significant difference was observed with regard to postoperative bowel obstruction. Overall, 30-days morbidity and postoperative length of stay were significantly higher for the EE group. Further randomized trials are required to verify our findings.

Long-term outcome of laparoscopic Nissen fundoplication in a regional hospital setting.

BACKGROUND: Laparoscopic Nissen fundoplication is considered to be the standard approach for the surgical treatment of gastroesophageal reflux disease. Various trials have assessed the outcome of the operation performed in high-volume centers, but the existing evidence regarding peripheral, low-volume hospitals is scarce. The purpose of this study is to investigate the late outcome of laparoscopic Nissen fundoplication with regard to symptom control and postoperative quality of life in a community-hospital setting. METHODS: 376 patients underwent laparoscopic Nissen fundoplication in our hospital during the period of 1997-2012. Patients were asked to subjectively; assess the pre- and postoperative severity of their symptoms and quality of life. Follow-up was conducted by means of a mailed questionnaire. RESULTS: Respondents had a median follow-up of 8.8 years (range: 1.4-17). 60.8% (101/166) patients reported complete control of heartburn. Ten patients (6%) had undergone revisional surgery. 31 respondents (18.6%) reported a new-onset dysphagia postoperatively. 85% (138/166) of the respondents would have; the operation again, if necessary. 73.6% (120/166) reported a lasting improvement of their overall quality of life. CONCLUSION: Laparoscopic Nissen fundoplication is a safe method with significant long-term efficacy in terms of symptom control and quality of life, even when; performed in a low-volume, community-hospital setting.

Transanal evisceration of the small bowel - report of a case.

Transanal intestinal evisceration is an extremely rare pathologic condition. Its presentation is quite dramatic as it involves the small bowel eviscerating through a rectal wall defect intraluminally and exiting transanally. We present the case of a 91-year-old female with history of rectal bleeding due to local ischemia of the anterior rectal wall, who presented to us with intestinal loops extruding through the anus. The patient underwent prompt surgical intervention with segmental small bowel resection, resection of the rectum, and construction of an end colostomy, with a smooth postoperative recovery. Our report highlights local ischemia of the anterior rectal wall as an etiopathogenic factor and stresses its role as an alarm sign for subsequent rectal perforation with evisceration of the small intestine.

Lightweight Titanium-coated Mesh Versus Standard-Weight Polypropylene Mesh in Totally Extraperitoneal Inguinal Hernia Repair (TEP): A Cohort Analysis.

PURPOSE: The study objective is to compare the outcomes of laparoscopic to tally extraperitoneal repair using the standard-weight polypropylene mesh or a lightweight titanium-coated mesh. METHODS: A retrospective review was conducted on 138 adult patients with unilateral inguinal hernias, who underwent totally extraperitoneal inguinal hernia repair between 2010 and 2013 using either a standard-weight polypropylene mesh (Prolene mesh, 80 g/m) or a lightweight titanium-coated mesh (Ti Mesh light, 35 g/m). RESULTS: There was no difference in reported pain at 24 hours postoperatively. The difference in reported pain at follow-up (mean: 21 mo) was insignificant [PP vs. Ti: 7.8% (n=5) vs. 8.3% (n=3), P=0.92], the differences regarding chronic inguinal pain was also insignificant [PP vs. Ti: 14% (n=9) vs. 5.5% (n=2), P=0.191], and there was no difference in the development of hernia recurrence [PP vs. Ti: 1.5% (n=1) vs. 0, P=0.42]. CONCLUSIONS: No statistically significant differences of the overall postoperative outcome were observed between the 2 mesh types.

Laparoscopic repair of giant hiatal hernia. A single center experience.

INTRODUCTION: Giant hiatal hernia is a rare clinical entity with possibly serious complications, diagnosed mostly among older patients. The laparoscopic repair of such hernias is a therapeutic option, performed mostly in specialized centers by experienced surgeons. METHODS: From 1997 to 2012 fifty-five patients with giant hiatal hernia (median age of 72) were primarily treated by laparoscopic surgery at the surgical department of the Catholic Clinic Oberhausen. Demographic data, operating times, conversion rate, morbidity and mortality were recorded prospectively. Follow-up was conducted by means of a mailed questionnaire. RESULTS: Intraoperative complications occurred in 1,8% of the cases (n = 1). In this single case the procedure was converted to an open procedure due to technical difficulties imposed by hepatomegaly. The median operating time was 96 min (range, 30 to 350). Our rate of postoperative complications was 14,5% (n = 8). The median postoperative hospital stay was nine days. 14,5% (n = 8) of our patients underwent a redo-surgery for symptomatic recurrence. The median follow-up was 64 months by means of a self-designed questionnaire. 34,5% (19/55) of the questioned patients responded to our survey. The difference between pre- and postoperative symptom intensity was found to be significant for heartburn (p < 0,001) and retrosternal/epigastric pain (p = 0,028). The difference was not found to be statistically significant for dysphagia (p = 0,8) and bloating (p = 0,3). 85% of the questioned patients stated they would have the operation again, if necessary. 80% reported an improvement of their overall quality of life. DISCUSSION: The laparoscopic repair of large hiatal hernias is a safe approach with an intraoperative complication rate of 1,8%, low post-operative morbidity (14,5%) and very low mortality (1,8%). There is a high patient satisfaction (85%) and a good postoperative quality of life (80%). CONCLUSION: The laparoscopic approach for repair of large hiatal hernias is a relatively safe method with significant long-term efficacy in terms of symptom control and quality of life.