A comparison of laparoscopic and open hernia repair as a day surgical procedure

Surg Endosc (1994) 8:1404-1408

Surgical Endoscopy © Springer-Verlag New York Inc. 1994

A comparison of laparoscopic and open hernia repair as a day surgical procedure G. J. M a d d e r n , 1 G. R u d k i n , 2 J. R. Bessell, 3 P. Devitt, 3 L. Ponte 1 XHepato-Biliary and Pancreatic Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000, Australia ZDay Surgery Unit, Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000, Australia 3Department of Surgery, University of Adelaide, South Australia 5005, Australia. Received 23 October 1994/Accepted 6 June 1994 Abstract. To evaluate the merits of laparoscopic in-

guinal hernia repair (LHR) compared to conventional open hernia repair (OHR) a randomized study has been conducted. All patients were day surgical cases, of which 44 were randomized to a standardized OHR under local anesthetic (LA) and 42 to an L H R under general anesthesia (GA). Fifteen L H R patients had bilateral repairs. Operative time for OHR was 30.5 min, for unilateral L H R 35 min, and for bilateral L H R 60 min. OHR patients were discharged after a median of 134.5 min, which was significantly shorter than L H R patients, whose median discharge was 225 min (P < 0.01). Pain scores, activity levels, analgesia requirements, and time taken to return to work were not significantly different following surgery in either group (P < 0.05). There have been two recurrent hernias and one small bowel obstruction in the L H R group. We conclude that both repairs can be successfully performed as day surgical procedures. The added cost of L H R at this stage does not warrant its widespread use in unilateral hernia repairs. Which procedure is adopted should be individualized; however, patients with bilateral hernias on presentation can be successfully managed as day cases, obviating the need for hospitalization or two operations. Key words: L a p a r o s c o p y - - Inguinal hernia - - Herniorrhaphy - - Day surgery

Correspondence to: G. J. Maddern, Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, South Australia 5011, Australia

Since his original description in 1887 [1] Bassini's operation has become a standard for inguinal hernia repairs. Since then, there have been many modifications to this repair, predominant being those described by Halsted [6, 7], McVay [10, 11] and Shouldice [16]. These techniques share the same principle of reduction and excision of the hernial sac with reconstruction and reinforcement of the posterior wall of the inguinal canal. More recently, the use of prostheses to buttress the posterior wall of the inguinal canal has been reported, using a preperitoneal approach [12, 17]. Nyhus et al. [12] placed a tailored piece of mesh as part of a preperitoneal repair of a recurrent defect. Stoppa and Warlaumont [17] repaired the hernia by suturing the mesh to the posterior wall of the inguinal canal rather than by the apposition of tissues. The preperitoneal approach using the prosthetic mesh has the advantage of covering the hernial defect as well as adjacent normal tissue beyond the limits of the defect, with intraabdominal pressure creating an efficient means of fixing the mesh over the site of the hernia. The first human laparoscopic herniorrhaphy was performed by Ger in 1979 [5]. His technique involved intraabdominal stapling of the neck of the hernial sac. Laparoscopic herniorrhaphy techniques have since evolved into three main groups: the transabdominal preperitoneal approach [3], the intraperitoneal onlay mesh technique [15], and the extraperitoneal inguinal herniorrhaphy method [9, 13]. S u b s e q u e n t reports of laparoscopic herniorrhaphies in humans have been few; the number of patients undergoing surgery and the follow-up period have usually been quite limited. The alleged advantages of laparoscopic herniorrhaphy have included reduced postoperative pain [2, 15], shorter hospital stay, and a more rapid return to work [2, 3, 9, 15]. In addition, while open hernia repair as a day surgical procedure is well established in many centers, the place of

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day surgery in laparoscopic hernia repair has not been critically assessed. Furthermore, to date there have not been any reported randomized controlled trials comparing the laparoscopic technique with a conventional open repair. The aim of this study was to compare a laparoscopic inguinal hernia repair to a conventional open approach in a day surgical unit, with assessment of postoperative pain, activity levels, clinical outcome, and cost.

All patients were reviewed the day after surgery by telephone and 3 days later in the Outpatients Clinic. Subsequently they were reviewed again in Outpatients on day 10 and day 30, and by telephone at 6-monthly intervals. On each occasion the patients were questioned regarding their pain and activity levels, which was recorded on an analogue scale of 0 to 10. In addition, the patients were asked to report the type and quantity of analgesics required, when they had returned to work or normal activity, and any complications. Patients were also contacted 30 days after surgery by a third party to gain their impression of the Day Surgery experience. They were asked to classify their experience as "very satisfied," "satisfied," "not satisfied," or "would not agree again." All results were analyzed using the Mann-Whitney U-test with a two-tailed a level of 0.05.

Materials and methods Eight-six patients (comprising 101 hernias) scheduled for elective inguinal hernia repair at the Royal Adelaide Hospital were investigated in a randomized controlled study. Patients were included based on the usual clinical indications for this operation. Patients were excluded from enrollment into this study if there was some contraindication to general anesthesia or any other medical condition precluding surgery. The patients were randomized to receive either the laparoscopic or open hernia repair, and a preoperative assessment was made regarding the presumed nature of the hernia (direct or indirect). All operations were performed by one of two consultant surgeons. Human Ethics Committee approval was gained and all patients gave their informed consent. The laparoscopic repair was performed under general anesthesia via a transabdominal approach, as the exclusively preperitoneal laparoscopic technique was not available when this study commenced. Access was via two 10-mm and one 5-mm cannulae, the umbilical port for the camera assembly, and bilateral iliac fossa ports for grasping, dissection, and stapling instruments. The peritoneum was incised above the hernial defect from within the abdomen and the hernial sac was invaginated. A polypropylene mesh (Prolene) was individually sized for each patient, introduced into the preperitoneal space, and stapled to the posterior wall of the inguinal canal using an Ethicon Endoscopic Multifeed Stapler (EMS). The peritoneum was then reapproximated with staples. The port holes were closed with 1 Ethibond and infiltrated with 0.25% Marcaine with 1:400,000 adrenaline. The open repair was performed under local anesthesia. A total of 50 ml of 1% Lignocaine with 1:100,000 adrenaline was infiltrated using a 22-gauge short-bevel needle to find the correct tissue plane for the ilioinguinal, iliohypogastric, and genitofemoral nerves and the peritoneal sac. The proposed incision was infiltrated with a 22gauge spinal needle. Additional analgesia was provided by further injection into the spermatic cord and pubic tubercle during the procedure with sedation when necessary. Excess hernial sac was dealt with by excision in the case of indirect hernias and by invagination in direct hernias. The posterior inguinal wall was repaired with a continuous 0 prolene suture overlain by a loose double darn of 0 prolene between the conjoint tendon and inguinal ligament. This is the standard open hernioplasty performed in our region. The wound was closed in layers and 20 ml of 0.25% Marcaine with 1:400,000 adrenaline was infiltrated. For both operations records were kept of operation time (skin incision to skin closure), consumables used, complications, and type of hernia found. All patients had their surgery performed as day cases in the Day Surgical Service of the Royal Adelaide Hospital. Patients were discharged on the same day provided there were no contraindications. Patients who required admission were transferred to a general surgical ward in the hospital. Upon discharge, patients were given 20 tablets of Panadeine Forte (oral paracetemol 500 mg plus codeine phosphate 30 mg) and 10 tablets of Oxycodone 5 mg, and a standardized list of instructions regarding pain, progress, hygiene, wound observations, lifting, sport, and driving. Patients were instructed to take one to two tablets of Panadeine Forte per 4 h as required for pain relief. If stronger analgesia was necessary they were advised to change to Oxycodone tablets, 5-10 mg/4 h as required. Patients were visited by the Royal District Nursing Service at their home on the following day, and subsequent visits were arranged as needed.

Results

There were 86 patients in the study, of whom 44 underwent conventional open hernia repair and 42 underwent laparoscopic hernia repair. Seventeen patients had bilateral hernias. Fifteen of these patients were randomized to have the laparoscopic repair with both hernias repaired simultaneously. Two patients with bilateral hernias were randomized to have the open repair and included as separate attendances because each hernia was repaired on a different occasion. One hundred one hernia repairs were performed in total. The median follow-up period to date is 243 days with a range of 160-436 days. All of the patients in the study were male with the exception of five females in the open group and two in the laparoscopic group. The measured parameters for the two groups of patients were given in Table 1. From the 42 patients who had an open repair only three required conversion to a general anesthetic. All patients undergoing the laparoscopic repair had general anesthesia. Table 1 indicates the type of hernias found at operation. The preoperative examination predicted the operative hernia type in 7% of cases excluding the pantaloon hernias, as none of the pantaloon hernias were confidently diagnosed prior to surgery. The median operation time for the bilateral operations performed laparoscopically was 60 min (range 30-100). When bilateral hernia repairs were excluded, the median operation time was not significantly different between the open and laparoscopic repairs. In contrast, in patients who were day cases and did not require admission the median postoperative discharge time was significantly shorter for the open group (P