The evolution of minimally invasive inguinal hernia repairs

BACKGROUNDCurrently, very few studies have examined the analgesic effectiveness and safety of dexmedetomidine-assisted intravenous-inhalation combined general anesthesia in laparoscopic minimally invasive surgery for inguinal hernia.AIMTo investigate the analgesic effect and safety of dexmedetomidine-assisted intravenous-inhalation combined general anesthesia in laparoscopic minimally invasive surgery for inguinal hernia.METHODSIn this retrospective study, 94 patients scheduled for laparoscopic minimally invasive surgery for inguinal hernia, admitted to Yiwu Central Hospital between May 2022 and May 2023, were divided into a control group (inhalation combined general anesthesia) and a treatment group (dexmedetomidine-assisted intravenous-inhalation combined general anesthesia). Perioperative indicators, analgesic effect, preoperative and postoperative 24-hours blood pressure (BP) and heart rate (HR), stress indicators, immune function levels, and adverse reactions were compared between the two groups.RESULTSBaseline data, including age, hernia location, place of residence, weight, monthly income, education level, and underlying diseases, were not significantly different between the two groups, indicating comparability (P > 0.05). No significant difference was found in operation time and anesthesia time between the two groups (P > 0.05). However, the treatment group exhibited a shorter postoperative urinary catheter removal time and hospital stay than the control group (P < 0.05). Preoperatively, no significant differences were found in the visual analog scale (VAS) scores between the two groups (P > 0.05). However, at 12, 18, and 24 hours postoperatively, the treatment group had significantly lower VAS scores than the control group (P < 0.05). Although no significant differences in preoperative hemodynamic indicators were found between the two groups (P > 0.05), both groups experienced some extent of changes in postoperative HR, diastolic BP (DBP), and systolic BP (SBP). Nevertheless, the treatment group showed smaller changes in HR, DBP, and SBP than the control group (P < 0.05). Preoperative immune function indicators showed no significant differences between the two groups (P > 0.05). However, postoperatively, the treatment group demonstrated higher levels of CD3+, CD4+, and CD4+/CD8+ and lower levels of CD8+ than the control group (P < 0.05). The rates of adverse reactions were 6.38% and 23.40% in the treatment and control groups, respectively, revealing a significant difference (χ2 = 5.371, P = 0.020).CONCLUSIONDexmedetomidine-assisted intravenous-inhalation combined general anesthesia can promote early recovery of patients undergoing laparoscopic minimally invasive surgery for inguinal hernia. It ensures stable blood flow, improves postoperative analgesic effects, reduces postoperative pain intensity, alleviates stress response, improves immune function, facilitates anesthesia recovery, and enhances safety.

Background:Radical prostatectomy (RP) represents an important acquired risk factor for the development of primary inguinal hernias (IH) with an estimated incidence rates of 15.9% within the first 2 years after surgery. The prostatectomy-related preperitoneal fibrotic reaction can make the laparoendoscopic repair of the IH technically difficult, even if safety and feasibility have not been extensively evaluated yet. We conducted a systematic review of the available literature.Methods:A comprehensive computer literature search of PubMed and MEDLINE databases was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Terms used to search were (‘laparoscopic’ OR ‘laparoscopy’) AND (‘inguinal’ OR ‘groin’ OR ‘hernia’) AND ‘prostatectomy’.Results:The literature search from PubMed and MEDLINE databases revealed 156 articles. Five articles were considered eligible for the analysis, including 229 patients who underwent 277 hernia repairs. The pooled analysis indicates no statistically significant difference of post-operative complications (Risk Ratios [RR] 2.06; 95% confidence interval [CI] 0.85–4.97), conversion to open surgery (RR 3.91; 95% CI 0.85–18.04) and recurrence of hernia (RR 1.39; 95% CI 0.39–4.93) between the post-prostatectomy group and the control group. There was a statistically significant difference of minor intraoperative complications (RR 4.42; CI 1.05–18.64), due to an injury of the inferior epigastric vessels.Conclusions:Our systematic review suggests that, in experienced hands, safety, feasibility and clinical outcomes of minimally invasive repair of IH in patients previously treated with prostatectomy, are comparable to those patients without previous RP.

As the ultimate procedure which each surgeon decides to perform for a unilateral uncomplicated inguinal hernia remains controversial, we queried the Americas Hernia Society Quality Collaborative (AHSQC) database to report the collective experience of surgeons in the United States whom contribute to AHSQC to provide a view of the surgical approaches performed. The AHSQC data registry was queried for all adult patients who underwent a primary, unilateral, elective, inguinal hernia repair. A retrospective review was conducted to analyze patient demographics, hernia characteristics, operative details, and post-operative outcomes. Our main outcomes of interest were 30-day surgical site infections (SSI), surgical site occurrences (SSO), 30-day patient-reported outcomes, and 1-year recurrence rates. 4613 patients met inclusion criteria. 1925 were repaired using an open technique (42%), 1841 were repaired using a laparoscopic technique (40%), and 847 were repaired using a robotic technique (18%). The Shouldice technique remains the most common tissue-based repair performed in the AHSQC. The Lichtenstein repair is the most common open mesh-based repair. Minimally invasive approaches to unilateral inguinal hernia repairs remained very common in our series. The robotic approach accounted for nearly one-third of the minimally invasive inguinal hernia repairs. In general, all of the repair techniques reported similar and low rates of 30-day complications. The AHSQC continues on-going efforts to improve long-term follow-up and looks forward to addressing long-term outcomes such as recurrence and chronic pain with increasing data acquisition.

Inguinal hernia repair is one of the most commonly performed surgical procedures worldwide, with over 20 million cases annually. The evolution of hernia surgery has transitioned from tension-based techniques to tension-free approaches, significantly reducing recurrence rates. This review explores the history, advancements, and current trends in minimally invasive inguinal hernia repair, focusing on laparoscopic techniques such as transabdominal preperitoneal (TAPP), totally extraperitoneal (TEP), single-incision laparoscopic surgery (SILS), and robotic-assisted repair. The importance of prosthetic meshes is emphasized, detailing their mechanical properties, pore size, weight classifications, and biocompatibility. Additionally, various mesh fixation methods-including tacks, sutures, and glues-are analyzed, with a discussion on their impact on postoperative complications such as chronic pain, adhesions, and infection risk. The debate between TAPP and TEP techniques is examined, highlighting the ongoing quest to determine the most effective approach. Emerging advancements, including drug-loaded meshes and dual-layered prosthetics, aim to improve integration and reduce complications. Despite significant progress, no universally superior technique or mesh exists, underscoring the need for individualized surgical approaches. Future research should focus on optimizing materials, refining fixation strategies, and enhancing patient outcomes in minimally invasive hernia repair.

Orchialgia is a rare but significant complication experienced after open and minimally invasive inguinal hernia repairs with or without mesh. Causes have been theorized to include trauma to the spermatic cord, mesh-induced inflammation, vascular insult, fibrosis or mesh scarring of the cord, and neuropathic injury to the autonomic paravasal nerve fibers supplying the testicle. Though less frequently described than inguinodynia, orchialgia can be severely debilitating. Retrospective review of consecutive adult patients who underwent surgical intervention for inguinodynia with coexisting orchialgia between September 2011 and April 2023. Primary outcome was percent improvement of orchialgia, reported by patients in postoperative follow up. Secondary outcomes included surgical approach, type of neurectomy performed, the need for orchiectomy, and remedial operations. A total of 173 patients were identified. Of this cohort, 89.6% (155) underwent paravasal neurectomy, 96% (166) underwent inguinal neurectomy, 14% (24) underwent orchiectomy, and 5.2% (9) underwent vasectomy. These operations were conducted via an open approach in 18% (31) and via hybrid approach in 62% (108). Improvement was noted in 99% (173) of cases, with greater than 50% improvement in pain in 64% (111). Orchialgia is less common than inguinodynia but is encountered in approximately 10% of patients with chronic pain after inguinal hernia repair resulting from all variants of operative repairs. Utilization of a patient-tailored surgical approach to address the likely mechanisms of testicular pain after prior inguinal hernia repair allows for favorable surgical results. A careful examination and assessment of the potential mechanisms of orchialgia after inguinal hernia repair allows for identification of specific causes and potential options for remediation.

The association of postoperative patient-reported outcomes and type of mesh fixation during minimally invasive inguinal hernia repair has not been well characterized. We aimed to compare the 30-day quality of life outcomes between various mesh fixation techniques utilizing the AHSQC prospective registry. All minimally invasive inguinal hernias with completed 30-day follow-up were abstracted from the AHSQC, excluding patients with primary indication for surgery being chronic groin pain. Mesh fixation was categorized as (1) atraumatic fixation (AF) (2) traumatic non-suture (TNS), (3) traumatic suture (TS). Our outcomes of interest were pain at site at 30-day and EuraHS quality of life assessment. After applying inclusion and exclusion criteria, 864 patients had surgical site pain and quality of life outcomes reported; 253 (AF), 451 (TNS), and 160 (TS). After adjusting for identified confounders, there was no statistically significant difference between any fixation method when evaluating pain as a binary variable (Yes/No). However, when looking at the EuraHS evaluation for pain and quality of life outcomes, AF was associated with better scores than both TNS and TS fixation in the cosmetic, restrictions, and overall EuraHS domains. AF was only better than TS fixation in the pain domain. Our study suggests that AF had a significantly improved hernia-specific quality of life in all domains at 30-days postoperatively. We also identified that pain as a binary variable is inadequate for its states purpose. Thus, the overall well-being and morbidity should be taken into account when evaluating hernia patients postoperatively.

BACKGROUND: We sought to evaluate change in postoperative prescription practices in an independent community-based hospital after hospital interventions and a state legislation change.STUDY DESIGN: This is a retrospective review of opioid-naïve adult subjects who underwent 5 common general surgical procedures between 2015 and 2017, including cholecystectomy, appendectomy, minimally invasive inguinal hernia repair, open inguinal hernia repair, and breast lumpectomy. Educational interventions were introduced, new statewide legislation was passed, and 129 subsequent cases were reviewed.RESULTS: Mean ± SD oral morphine equivalent (OME) prescribed for all procedures on retrospective review was 218.8 ± 113.7 (n = 722), cholecystectomy 235.3 ± 133.8 (n = 248), appendectomy 220.2 ± 103.2 (n = 175), open inguinal hernia repair 214.4 ± 97.2 (n = 119), minimally invasive inguinal hernia repair 187.7 ± 87.8 (n = 117), and lumpectomy 212.5 ± 114.5 (n = 63). There was significant variation in OME prescribed by procedure and by surgeon (p = 0.006 and p = 0.008, respectively). Review of post-intervention cases showed a significant reduction in the OME prescribed each year (mean OME 197.6 in 2015 to 2017 vs 72.3 in 2018; p < 0.005), and a 60% to 70% reduction in mean OME per procedure. Post-intervention data also revealed resolution of previously seen variation in prescription practices, and a significant increase in the percentage of patients prescribed multimodal pain therapy (23.5% in 2015 to 2017 to 31.5% in 2018; p < 0.05).CONCLUSIONS: We achieved a 60% to 70% decrease in postoperative opioid prescription at our community hospital for 5 common surgical procedures, and resolution of variation in opioid prescription practices after a hospital-wide intervention and statewide legislation.Published by Elsevier Inc. PMID: 30880121

Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair. A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention. Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective. Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.

Minimally Invasive Inguinal Hernia Repair: TAPP, TEP, and eTEP Approaches