Centrum för kirurgisk vetenskap CFSS / Center for Surgical Sciences CFSS
Abstract
Minimally invasive laparoscopic and open tension-free techniques have
been evolved during the 1990's. Different laparoscopic techniques have
been used, where the totally extraperitoneal hernioplasty (TEP) is a
technically demanding but probably a better approach to minimally
invasive hernia surgery than the transabdominal preperitoneal technique
(TAPP), which may increase the risk of adhesions and postoperative
intestinal obstruction. TEP has been criticized because of expensive
disposable equipment. The standard polypropylene mesh used in
tension-free operations induces a strong foreign tissue reaction with
potentially harmful effects. A mesh with less polypropylene could
possibly be beneficial.
The aim of this thesis was to evaluate and compare different minimally
invasive techniques and meshes for inguinal hernia.
In three randomized controlled multi-center studies 1212 patients were
randomized and included in follow-up: TEP with or without the use of a
dissection balloon (322 patients); TEP using only reusable instruments,
mesh-plug or Lichtenstein (299 patients); Lichtenstein with Prolene or
Vyproll (which contains less polypropylene) mesh (591 patients). In the
last study all randomization and entering of data was performed online in
a database through the Internet, which facilitated the completion of the
trial. More than 80% of all patients in the studies were operated on in
day- surgery.
There were more conversions to TAPP or an open technique if a balloon not
was used. However the majority of the conversions occurred early in the
learning curve, which indicates that the use of a dissection balloon can
be helpful during the learning curve, but in experienced hands it just
adds costs to the operation, without offering additional benefits
The operation time was shorter in the mesh-plug group compared to
Lichtenstein and TER Postoperative pain was diminished after TEP compared
to open repair. The time to return to work was shorter after TEP than
Lichtenstein (5 vs. 7 days). The time of rehabilitation was shorter after
TEP than mesh-plug or Lichtenstein (14 vs. 24.5 vs. 28.5 days). There was
a tendency of more pain after Lichtenstein than after TEP or mesh-plug at
follow-up. Laparoscopic hernioplasty (TEP) is superior to tension-free
open herniorrhaphy with Mesh-plug and patch or Lichtenstein's operation
in terms of postoperative pain and rehabilitation.
There was no significant difference between Lichtenstein with Prolene or
Vyproll concerning postoperative pain, complications, rehabilitation or
quality of life.
All patients (n=33 275) with a unilateral primary inguinal or femoral
hernia with only one operation recorded in the Swedish Hernia Register
1992-2000 were linked to the Swedish Inpatient Register and the Swedish
Death Register for the period 1987-2000. The highest adjusted relative
risk (RR) of postoperative intestinal obstruction was found in patients
with previous multiple admissions for abdominal operations/inflammations,
including intestinal obstruction, 58.99. The RR was 2.79 with TAPP and
0.57 with TEP compared to Lichtenstein operated patients