ART OF MEDICINE 2017
IMPROVEMENT OF SURGICAL TREATMENT FOR PRIMARY INGUINAL HERNIAS BY APPLICATION OF MODIFIED PREPERITONEAL ALOHERNIOPLASTY TECHNIQUE
S.I. Savoliuk, M.Yu. Krestianov, A.Yu. Glagolieva
Abstract. The article has established benefits of modified laparoscopic techniques of preperitoneal alohernioplasty without fixation to the preperitoneal space with the reconstruction of the preperitoneal flap defect with welding technology. Reduction of surgery duration, length of hospital stay and recovery period with a decrease in the need of analgesic administration in the postoperative period compared with open inguinal Lichtenstein alohernioplasty was demonstrated. High-frequency welding of the peritoneum edges determined to be safe and a reliable method of preperitoneal space closure in experiment.
Introduction. The ways of surgery technique improvement aim at optimizing both short-term outcomes and quality of life of the patients considering the safety of surgical interventions. In particular, the successful implementation of inguinal hernioplasty as one of the most common operations, according to the latest trends in the world clinical practice includes low rate of perioperative complications, prevention of hernia recurrence, and satisfactory quality of life and comfort of patients in the long-lasting period. To ensure the best surgical results in early and late period after hernioplasty the least traumatic and at the same time reliable in terms of complications and recurrence prevention materials and techniques should be used.
A minimally invasive TAPP procedure is widely performed for inguinal hernia repair and involves creation of preperitoneal flap for handling the hernial bag and dissection of preperitoneal space with following implantation. There are several methods of peritoneum defect reconstruction including ligation, use of tackers and staplers. Since no unique algorithm for preperitoneal space closure has been developed yet, there is a need to search for the most optimal method that would allow reducing the operation time, preventing the recurrence, not affecting the quality of life.
Materials and methods. In a retrospective clinical study, 104 patients (men - 60, women - 44) aged 18-88 (the average age was 46 ± 2.1 years) with primary inguinal hernias unilateral hernias were included after a comprehensive examination.
The experimental part of the study was conducted on 12 rabbits of “Ukrainian Chinchilla” line weighing 1.95 - 3.75 kg (average weight was 2.30 ± 0.52).
Results and discussions. A significant difference in the mean length of hospital stay and period until regaining the ability to perform professional tasks was noticed by comparing the average data obtained by analysis of variance using F-test. The length of hospital stay was reduced by 4.2 times and the period until restoring the ability to perform professional duties by 3.4 times in the group where a new surgical method had been applied. No significant difference in the levels of postoperative complications (3.85 and 5.77%; p = 0.036) and reoperation due to complications (0 and 0.96%; p = 0.023) was found. A significant difference in terms of pain at rest (3.19 and 6.38%; p <0.001), pain at exertion (7.44 and 11.28%; p <0.001), chronic pain that needed treatment (2.31 and 3.83%; p <0.001), recurrence levels (0 to 3.85%; p <0.001) was observed. Cox-regression analysis of the risk of bleeding showed that the occurrence of this complication was associated with chronic administration of anticoagulants (warfarin, sincumar) and antiplatelet agents (aspirin-containing drugs) due to the presence of comorbidities (p <0.001). The multivariate analysis determined that the type of surgery (Liechtenstein against the proposed surgical method) is an independent risk factor for recurrence of inguinal hernia (OR - 1.775, 95% CI -0.549 - 2.093) and chronic inguinal pain (OR - 1.420, 95% CI -1.335 - 1.596). High BMI and medial hernia according to EHS classification were also among the main risk factors for recurrence. No case of the non-fixed 3D Bard™ mesh migration was registered.
The use of anatomically conformed prosthetic mesh implantation in preperitlneal space and the closure of peritoneal flap by high-frequency welding resulted in reduction of the need for analgesics in the early postoperative period (p˂0.001) and risk of long-lasting inguinal pain (p˂0.001). In experimental animals, the inflammatory reaction around the welded suture of the peritoneum demonstrated no statically significant increase of adhesion formation risk (p˃0.05) and reduction of the number of living mesotheliocytes was not associated with increased expression of inflammatory response (p˂0.001). The degree of fibrosis in the connecting line was higher in welding suture than in ligated, which provided greater tissue strength. Thus, the admissibility of the method of biological tissue welding for peritoneal defect closure due to its reliability, efficiency and safety was established.
Conclusions and prospects for further studies. 1. The modified laparoscopic preperitoneal alohernioplasty for primary inguinal unilateral hernias that includes anesthesia of trocar wounds, terminal anesthesia of peritoneum and diaphragm, peritoneum hydropreparation for dissection of preperitoneal space, implantation of anatomically conformed mesh prosthesis without fixation and reconstruction of the peritoneal defect by electric welding is an effective and reliable technique in terms of the level of perioperative complications, quality of life of patients in the short- and long-term periods after surgery and the risk of recurrence.
- 2. Macroscopic and morphological changes of the peritoneum at different time points after the intervention in patients after the use electric welding require further studies.
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- Ayiomamitis G.D. Tacks-free transabdominal preperitoneal (TAPP) inguinal hernioplasty, using an anatomic 3-dimensional lightweight mesh with peritoneal suturing: pain and recurrence outcomes-initial experience / G.D. Ayiomamitis, A.Zaravinos, P.C. Stathakis, et al. // Surg Laparosc Endosc Percutan Tech. – 2013. – V.23. – No.4. – P.150–155.
- Bittner R. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)] / R. Bittner, M.E. Arregui, T. Bisgaard // Surg Endosc. – 2011. – No. 25. - P. 2773–2843.
- Burgmans J.P. Long-term Results of a Randomized Double-blinded Prospective Trial of a Lightweight (Ultrapro) vs a Heavyweight Mesh (Prolene) in Laparoscopic Total Extraperitoneal Inguinal Hernia Repair (TULP-trial) / J.P. Burgmans, C.E. Voorbrood, R.K. Simmermacher et al. // Ann Surg. – 2016. – No.263. – P. 862-6.
- Cavazzola L.T. Laparoscopic versus open inguinal hernia repair / Cavazzola L.T., Rosen M.J.// Surg Clin North Am. – 2013. – No.93. – P.1269–1279.
- Khajanchee Y.S. Outcomes of laparoscopic herniorrhaphy without fixation of mesh to the abdominal wall / Khajanchee Y.S., Urbach D.R., Swanstrom L.L., et al. // Surg Endosc. – 2001. – V. 15. – No. 10. – P. 1102–1107.
- Lange J.F. An international consensus algorithm for management of chronic postoperative inguinal pain / J.F. Lange, R. Kaufmann, A.R. Wijsmuller et al // Hernia. – 2015. – No.19. – P.33–43.
- Mayer F. When is mesh fixation in TAPP-repair of primary inguinal hernia repair necessary? The register-based analysis of 11,230 cases / F. Mayer, H. Niebuhr, M. Lechner // Surg Endosc. – 2016. – No.10. – P. 4363-71.
- Oguz H. Comparison of peritoneal closure techniques in laparoscopic transabdominal preperitoneal inguinal hernia repair: a prospective randomized study / H. Oguz, E. Karagulle, E. Turk, et al. //Hernia. – 2015. – No.6. – P.879-85.
- Ross S.W. Tacks, staples, or suture: method of peritoneal closure in laparoscopic transabdominal preperitoneal inguinal hernia repair effects early quality of life / S.W. Ross, B. Oommen, M. Kim et al. //Surg Endosc. – 2015. – V.29. – No.7. – P. 1686-93.