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   2006| July-September  | Volume 2 | Issue 3  
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Evaluation of various prosthetic materials and newer meshes for hernia repairs
HG Doctor
July-September 2006, 2(3):110-116
DOI:10.4103/0972-9941.27721  PMID:21187889
The use of prosthesis has become essential for repair of all hernias since the recurrence rates are consistently lower when they are used. To fulfill this requirement, a variety of newer meshes have been engineered. An ideal prosthesis should be strong, pliable, non-allergenic, inert, non-biodegradable, non-carcinogenic and should stimulate adequate fibroblastic activity for optimum incorporation into the tissues. Prosthesis used for hernia repairs can be non-absorbable, composite (combination of absorbable and non-absorbable fibres) or with an absorbable or a non-absorbable barrier. Surgeons should acquire sufficient knowledge of different types of prosthesis so as to select an appropriate one for a given case. Non-absorbable or composite mesh is recommended for hernia repair where it will not come in contact with the bowel. Prosthesis with a barrier only should be used for intra-abdominal placement to prevent bowel adhesions since it is increasingly difficult to defend the use of a biomaterial that has no adhesion barriers. This review highlghts all these different types of meshes and their appropriate selection for a given hernia repair. Selection of the optimum size and its proper fixation is mandaory. Complications can be avoided or minimized with proper selection of mesh for a given case and by performing the surgery with a meticulous technique.
  21 11,609 638
Tension free open inguinal hernia repair using an innovative self gripping semi-resorbable mesh
Philippe Chastan
July-September 2006, 2(3):139-143
DOI:10.4103/0972-9941.27726  PMID:21187984
Aims: Inguinal hernia repair according to Lichtenstein technique has become the most common procedure performed by general surgeons. Heavy weight polypropylene meshes have been reported to stimulate inflammatory reaction responsible for mesh shrinkage when scar tissue evolved. Additionally, some concerns remain regarding the relationship between chronic pain and mesh fixation technique. In order to reduce those drawbacks, we have developed a new mesh for anterior tension free inguinal hernia repair which exhibits self-gripping absorbable properties. Materials and Methods: 52 patients (69 hernias) were prospectivly operated with this mesh (SOFRADIM-France) made of low-weight isoelastic large pores knitted fabric which incorporated resorbable micro hooks that provides self gripping properties to the mesh during the first months post-implantation. The fixation of the mesh onto the tissues is significantly facilitated. The mesh is secured around the cord with a self gripping flap. After complete tissular ingrowth and resorption of the PLA hooks, the low-weight (40 g/m2) polypropylene mesh insures the long term wall reinforcement. Results: Peroperativly, no complication was reported, the mesh was easy to handle and to fix. Discharge was obtained at Day 1. No perioperative complication occurred, return to daily activities was obtained at Day 5.5. At one month, no neurological pain or other complications were described. Conclusions: Based on the first results of this clinical study, this unique concept of low density self gripping mesh should allows an efficient treatment of inguinal hernia. It should reduce postoperative complications and the extent of required suture fixation, making the procedure more reproducible
  21 12,608 467
Light weight meshes in incisional hernia repair
Volker Schumpelick, Uwe Klinge, Raphael Rosch, Karsten Junge
July-September 2006, 2(3):117-123
DOI:10.4103/0972-9941.27722  PMID:21187980
Incisional hernias remain one of the most common surgical complications with a long-term incidence of 10-20%. Increasing evidence of impaired wound healing in these patients supports routine use of an open prefascial, retromuscular mesh repair. Basic pathophysiologic principles dictate that for a successful long-term outcome and prevention of recurrence, a wide overlap underneath healthy tissue is required. Particularly in the neighborhood of osseous structures, only retromuscular placement allows sufficient subduction of the mesh by healthy tissue of at least 5 cm in all directions. Preparation must take into account the special anatomic features of the abdominal wall, especially in the area of the Linea alba and Linea semilunaris. Polypropylene is the material widely used for open mesh repair. New developments have led to low-weight, large-pore polypropylene prostheses, which are adjusted to the physiological requirements of the abdominal wall and permit proper tissue integration. These meshes provide the possibility of forming a scar net instead of a stiff scar plate and therefore help to avoid former known mesh complications.
  16 13,280 527
Hernia recurrence as a problem of biology and collagen
Uwe Klinge, Marcel Binnebosel, Raphael Rosch, Peter Mertens
July-September 2006, 2(3):151-154
DOI:10.4103/0972-9941.27729  PMID:21187987
Usually an abdominal wall hernia is regarded as a mechanical problem with a local defect which has to be closed by technical means. Despite the introduction of several therapeutic improvements, recurrent hernias still appear in 10-15%. Therefore, reasons for a recurrence are discussed in a more fundamental way. It is assumed that a failure mainly depends on the quality of the repair. Correspondingly, in principle, the close causal relationship between the technical component and its failure during time is reflected by an s-shaped outcome curve. In contrast, the configuration of the outcome curve changes markedly if a breakdown is caused by numerous components. Then, the superposition of all incidence curves inevitably leads to a linear decline of the outcome curve without any s-shaped deformation. Regarding outcome curves after hernia repair, the cumulative incidences for recurrences of both incisional and inguinal hernia show a linear rise over years. Considering the configuration of outcome curves of patients with hernia disease, it may therefore be insufficient to explain a recurrence just by a failing technical repair. Rather, biological reasons should be suspected, such as a defective wound healing with impaired scarring process. Recent molecular-biological findings provide increasing evidence of underlying biochemical alterations in patients with recurrent hernia. Until predicting markers to identify patients with an impaired wound healing are available and considering the formation of insufficient scar as the underlying disease, the consequences for every surgical repair should be a supplementary reinforcement with nonabsorbable alloplastic nets as flat meshes with an extensive overlap.
  16 10,527 327
Causes of recurrence in laparoscopic inguinal hernia repair
Jan F Kukleta
July-September 2006, 2(3):187-191
DOI:10.4103/0972-9941.27736  PMID:21187994
Aim: The analysis of possible mechanisms of repair failure is a necessary instrument and the best way to decrease the recurrence rate and improve the overall results. Avoiding historical errors and learning from the reported pitfalls and mistakes helps to standardize the relatively new laparoscopic techniques of trans-abdominal preperitoneal and total extraperitoneal. Materials and Methods: The video tapes of all primary laparoscopic repairs done by the author that led to recurrence were retrospectively analyzed and compared with findings at the second laparoscopic repair. A review of the available cases of recurrences occurring between 1994 and 2003 is the basis of this report. Summary: Adequate mesh size, porosity of mesh material, slitting of the mesh, correct and generous dissection of preperitoneal space and wrinkle-free placement of the mesh seem to be the more important factors in avoiding recurrence rather than strength of the material or strong penetrating fixation. Special attention should be paid to preperitoneal lipoma as a possible overlooked herniation or potential future pseudorecurrence despite nondislocated correctly positioned mesh. Conclusion: Laparoscopic hernia repair is a complex but very efficient method in experienced hands. To achieve the best possible results, it requires an acceptance of a longer learning curve, structured well-mentored training and high level of standardization of the operative procedure.
  10 18,821 488
TAPP - Stuttgart technique and result of a large single center series
R Bittner, BJ Leibl, C Jager, B Kraft, M Ulrich, J Schwarz
July-September 2006, 2(3):155-159
DOI:10.4103/0972-9941.27730  PMID:21187988
Laparoscopic hernioplasty is assessed as a difficult operation. Operative technique determines the frequency of complications, the time of recovery and the rate of recurrences. A proper technique is absolutely necessary to achieve results that are superior to open hernia surgery. Technique: The key points in our technique are 1) use of nondisposable instruments; 2) use of blunt trocars, consisting of expanding and non-incisive cone-shaped tips; 3) spacious and curved opening to the peritoneum, high above all possible hernia openings; 4) meticulous dissection of the entire pelvic floor; 5) complete reduction of the hernial sac; 6) wide parietalization of the peritoneal sac, at least down to the mid of psoas muscle; 7) implantation of a large mesh, at least 10 cm 15 cm; 8) fixation of the mesh by clip to Cooper's ligament, to the rectus muscle and lateral to the epigastric vessels, high above the ileopubic tract; 9) the use of glue allows fixation also to the latero-caudial region; and 10) closure of the peritoneum by running suture. Results: With this technique in 12,678 hernia repairs, the following results could be achieved: operating time - 40 min; morbidity - 2.9%; recurrence rate - 0.7%; disability of work - 14 days. In all types of hernias (recurrence after previous open surgery, recurrence after previous preperitoneal operation, scrotal hernia, hernia in patients after transabdominal prostate resection), similar results could be achieved. Summary: Laparoscopic hernia repair can be performed successfully in clinical practice even by surgeons in training. Precondition for the success is a strictly standardized operative technique and a well-structured educational program.
  9 8,594 298
Complications in groin hernia surgery and the way out
Pradeep K Chowbey, Murtaza Pithawala, Rajesh Khullar, Anil Sharma, Vandana Soni, Manish Baijal
July-September 2006, 2(3):174-177
DOI:10.4103/0972-9941.27734  PMID:21187992
Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than those of open surgery, especially in inexperienced hands and hence are best avoided. It is possible to avoid most of these complications if one follows a set of well-defined steps and principles of endoscopic inguinal hernia surgery. Complications are known to occur at each and every step of hernia surgery. Applying caution while performing each step can save the patient from a lot of morbidity. One starts by applying strict patient selection criteria for endoscopic hernia repair, especially in the initial part of ones learning curve. A thorough knowledge of anatomy goes a long way in avoiding most of the complications seen in hernia repair. This anatomy needs to be relearned from what one is used to, as the approach is totally different from an open hernia repair. And finally, learning and mastering the right technique is an essential prerequisite before one ventures into inguinal hernia repair. Although there has been an increased incidence of complications reported in endoscopic repair in the earlier series, this can be explained partly by the fact that it was in the early part of the learning curve of most endoscopic surgeons. As the experience grew and the techniques were standardized, the incidences of complications have also reduced and have come to be on par with open hernia surgery. The various complications and precautions to be taken to avoid them will be discussed.
  8 14,531 469
A modified Lichtenstein hernia repair using fibrin glue
Giampiero Campanelli, Diego Pettinari, Marta Cavalli, Ettore Contessini Avesani
July-September 2006, 2(3):129-133
DOI:10.4103/0972-9941.27724  PMID:21187982
In recent years, general surgeons who perform inguinal hernia repair have paid attention to successful reduction in the recurrence rate. The Lichtenstein technique is widely used because it is easy to learn and is associated with a low rate of complication and recurrences. Today, the new objective in primary hernia surgery should be to reduce complications such as chronic pain. Chronic pain after hernia repair can be disabling, with considerable impact on quality of life and there is evidence to suggest increased use of health services by patients who have chronic pain. We have proposed an international randomized controlled trial with seven referenced European centers: The TI.ME.LI. trial. The aim of this study is to evaluate pain and further disabling complications in patients undergoing Lichtenstein technique for primary inguinal hernia repair by fixing the mesh with fibrin sealant versus sutures (control group).
  7 8,496 385
Inguinal hernia repair: The total picture
Tehemton E Udwadia
July-September 2006, 2(3):144-146
DOI:10.4103/0972-9941.27727  PMID:21187985
  6 11,762 522
Inguinal hernia recurrence: Classification and approach
Giampiero Campanelli, Diego Pettinari, Marta Cavalli, Ettore Contessini Avesani
July-September 2006, 2(3):147-150
DOI:10.4103/0972-9941.27728  PMID:21187986
The authors reviewed the records of 2,468 operations of groin hernia in 2,350 patients, including 277 recurrent hernias updated to January 2005. The data obtained - evaluating technique, results and complications - were used to propose a simple anatomo-clinical classification into three types which could be used to plan the surgical strategy:
  • Type R1: first recurrence 'high,' oblique external, reducible hernia with small (<2 cm) defect in non-obese patients, after pure tissue or mesh repair
  • Type R2: first recurrence 'low,' direct, reducible hernia with small (<2 cm) defect in non-obese patients, after pure tissue or mesh repair
  • Type R3: all the other recurrences - including femoral recurrences; recurrent groin hernia with big defect (inguinal eventration); multirecurrent hernias; nonreducible, linked with a controlateral primitive or recurrent hernia; and situations compromised from aggravating factors (for example obesity) or anyway not easily included in R1 or R2, after pure tissue or mesh repair.
  6 10,164 434
The Shouldice technique for the treatment of inguinal hernia
Chin Keung Chan, Gabriel Chan
July-September 2006, 2(3):124-128
DOI:10.4103/0972-9941.27723  PMID:21187981
The Shouldice repair has been refined over several decades and is the gold standard for the prosthesis-free treatment of inguinal hernias. A recurrence rate around 1% has been consistently demonstrated over the years. The objective of this paper is to outline and highlight the key principles, including the dedicated pre-operative preparation, the use of local anesthesia, a complete inguinal dissection and the eponymous four-layered reconstruction. A knowledge and understanding of inguinal hernia anatomy and the patho-physiology of recurrence are vital to achieving a long-term success and patient satisfaction for a pure tissue repair.
  6 26,994 691
Laparoscopic repair of ventral / incisional hernias
Pradeep K Chowbey, Anil Sharma, Magan Mehrotra, Rajesh Khullar, Vandana Soni, Manish Baijal
July-September 2006, 2(3):192-198
DOI:10.4103/0972-9941.27737  PMID:21187995
Despite its significant prevalence, there is little in the way of evidence-based guidelines regarding the timing and method of repair of incisional hernias. To add to the above is the formidable rate of recurrence that has been seen with conventional tissue repairs of these hernias. With introduction of different prosthetic materials and laparoscopic technique, it was hoped that an improvement in the recurrence and complication rates would be realized. The increasing application of the laparoscopic technique across the world indicates that these goals might indeed be achieved.
  6 7,597 394
Laparoscopic surgery for inguinal hernia: Current status and controversies
Deepraj S Bhandarkar, Manu Shankar, Tehemton E Udwadia
July-September 2006, 2(3):178-186
DOI:10.4103/0972-9941.27735  PMID:21187993
Repair of inguinal hernia is one of the commonest operations performed by surgeons around the world. The treatment of this common problem has seen an evolution from the pure tissue repairs to the prosthetic repairs and in the recent past to laparoscopic repair. The fact that so many hernia repairs are practiced is a testimony to the fact that probably none is distinctly superior to the other. This review assesses the current status of surgery for repair of inguinal hernia and examines the various controversial issues surrounding the subject.
  4 9,007 457
Sir Ganga Ram Hospital classification of groin and ventral abdominal wall hernias
Pradeep K Chowbey, Rajesh Khullar, Magan Mehrotra, Anil Sharma, Vandana Soni, Manish Baijal
July-September 2006, 2(3):106-109
DOI:10.4103/0972-9941.27720  PMID:21187888
Background: Numerous classifications for groin and ventral hernias have been proposed over the past five to six decades. The old, simple classification of groin hernia in to direct, inguinal and femoral components is no longer adequate to understand the complex pathophysiology and management of these hernias. The most commonly followed classification for ventral hernias divide them into congenital, acquired, incisional and traumatic, which also does not convey any information regarding the predicted level of difficulty. Aim: All the previous classification systems were based on open hernia repairs and have their own fallacies particularly for uncommon hernias that cannot be classified in these systems. With the advent of laparoscopic/ endoscopic approach, surgical access to the hernia as well as the functional anatomy viewed by the surgeon changed. This change in the surgical approach and functional anatomy opened the doors for newer classifications. The authors have thus proposed a classification system based on the expected level of intraoperative difficulty for endoscopic hernia repair. Classification: In the proposed classification higher grades signify increasing levels of expected intraoperative difficulty. This functional classification grades groin hernias according to the: a) Pre -operative predictive level of difficulty of endoscopic surgery, and b) Intraoperative factors that lead to a difficult repair. Pre operative factors include multiple or pantaloon hernias, recurrent hernias, irreducible and incarcerated hernias. Intraoperative factors include reducibility at operation, degree of descent of the hernial sac and previous hernia repairs. Hernial defects greater than 7 cm in diameter are categorized one grade higher. Conclusion: Though there have been several classification systems for groin or inguinal hernias, none have been described for total classification of all ventral hernias of the abdomen. The system proposed by us includes all abdominal wall hernias and is a final classification that predicts the expected level of difficulty for an endoscopic hernia repair.
  4 9,049 354
Totally extraperitoneal repair of inguinal hernia: Sir Ganga Ram Hospital technique
Pradeep K Chowbey, Rajesh Khullar, Anil Sharma, Vandana Soni, Manish Baijal
July-September 2006, 2(3):160-164
DOI:10.4103/0972-9941.27731  PMID:21187989
Laparoscopic approach for hernia has evolved rapidly over the past decade. We adopted the TEP repair early as we believe in preserving the sanctity of the coelomic cavity. Once well versed with the approach we have found it an efficient and cost effective method for groin hernia repair. Endoscopic totally extraperitoneal hernia repair is a technically demanding procedure. Indepth anatomical knowledge, training and advanced technical skill is needed for the surgeon to perform this procedure. To make the procedure cost effective and prevent hernia recurrences, we have modified and innovated to simplify the procedure. This modification which we have named the SGRH technique, innovates by creating the preperitoneal working space with the help of an indigenous glove finger balloon. A rolled mesh makes placement and fixation easier in the limited working space. The mesh is unrolled on the peritoneal surface (floor), a manouver which is technically simpler. On desufflation the mesh comes to appose the Fruchad's orifice covering all potential hernial sites. With the modified SGRH technique we have found TEP to be safe, cost effective, reproducible and without significant complications.
  3 6,744 306
Managing intra-operative complications during totally extraperitoneal repair of inguinal hernia
Davide Lomanto, Avinash N Katara
July-September 2006, 2(3):165-170
DOI:10.4103/0972-9941.27732  PMID:21187990
Laparoscopic inguinal hernia repairs are looked upon as technically demanding procedures having have a stiff 'learning curve' associated with its performance in terms of clinical outcome and patient's satisfaction. Complication rates have been shown to drop with increased surgical experience. The complication rate for laparoscopic repair of inguinal hernia ranges from less than 3% to as high as 20%. Complications of a totally extraperitoneal (TEP) repair include general complications that occur with any surgical procedure and anesthesia, mesh-related complications and those specific to the TEP procedure, like visceral injury, vascular injury, nerve injury and injury to the cord. Intraoperative complications can occur at every step of the operation, even though some of them are only occasionally reported. However, it is important to analyze all of them chronologically, so that we can define methods to prevent them or tackle them if they occur. Risk reduction strategies are required to improve the clinical outcome of TEP and this must be adopted for each individual surgical step.
  3 8,435 349
Cure of inguinal hernias with large preperitoneal prosthesis: Experience of 2,312 cases
JH Alexandre, JL Bouillot, P Dupin, K Aouad, JP Bethoux
July-September 2006, 2(3):134-138
DOI:10.4103/0972-9941.27725  PMID:21187983
It is clear that the recurrence rates after nonprosthetic methods for the repair of inguinal hernias, like McVay, Bassini or Shouldice techniques, are high (6-10%). Since 20 years, we are convinced, in the GREPA-EHS group, about the advantages of the use of a prosthetic mesh in majority of patients for repairs of primary or recurrent inguinal hernias and incisional hernias. We describe our typical technique for the cure of all inguinal hernias. We place a large supple mesh, by open inguinal route, posterior to the transversalis fascia and anterior to the peritoneum. We have made a double modification in the initial technique of Rives - the use of a very large unsplit prosthesis (15 17 cm) and the parietalization of the spermatic cord helped by a wide opening of the Fruchaud's orifice by diversion of the epigastric vessels. The positioning of the mesh is about the same as in the TEP technique but with the advantages of reduction in the vital laparoscopic risks and reinforcement of the wall by a short tension-free McVay technique. For this prospective study, we repaired 2,312 consecutive hernias in 1,828 patients, 284 of which were recurrent. We present our results in terms of quality of repairs, recurrence rates (0.4%), morbidity rate (8%), and mortality rate (0.8%). This technique involves the placement by an open incisional route of a large preperitoneal sheet of mesh for initial treatment of all inguinal hernias - including scrotal, giant or femoral - to ensure a definitive solid muscular wall, even for recurrent hernias.
  2 5,898 260
Totally extraperitoneal repair of inguinal hernia: A case for bilateral repair
Pradeep K Chowbey, Murtaza Pithawala, Rajesh Khullar, Anil Sharma, Vandana Soni, Manish Baijal
July-September 2006, 2(3):171-173
DOI:10.4103/0972-9941.27733  PMID:21187991
Inguinal hernia surgery has been one of the most extensively debated and continues to evolve in search for the ideal technique. Even though the method to diagnose hernia has largely remained clinical, recently other modalities have detected hernias that are not picked up on clinical examination or are incorrectly labeled. Laparoscopy, for the first time has given surgeons the unique opportunity to look at both sides of the groin and to detect and study the contra lateral groin in a patient of clinically unilateral hernia. This has given rise to some interesting findings. In the pediatric age group the value of bilateral detection and repair has been extensively debated. However, the same is not true for the adults despite the facts that there are better methods for detection, better understanding of pathogenesis of hernia and better repair techniques that can take care of bilateral repair without adding to morbidity. That hernia is not a simple derivative of patent processus vaginalis or strain related cause is beginning to be better understood now. It may primarily be a disorder of collagen metabolism with genetic basis. Laparoscopy has also made us wiser in detection of type of hernia and examination of both groin areas. In several studies there have been a high percentage of undetected hernias or additional defects. This was never realized earlier as in open surgery there is no question of exploring the asymptomatic groin. Laparoscopy in bilateral repair is safe and does not add significantly to the operating time, cost or morbidity. At our Department of Minimal Access Surgery, Sir Ganga Ram Hospital, New Delhi, India we have been performing Endoscopic Totally Extraperitoneal (TEP) repair for all simple and complicated inguinal hernia since 1994. We now routinely perform a bilateral repair based on our understanding that the pathogenesis of hernia is a complex process and any genetic basis of collagen disorder has to affect the patient bilaterally. The clinical examination may have unacceptably low sensitivity. Early identification and repair obviates the need for reoperation, reduces overall costs and eliminates further anaesthetic and operative risks for the patient
  1 6,052 246
Surgery for hernia: quo vadis?
Tehemton E Udwadia
July-September 2006, 2(3):104-105
DOI:10.4103/0972-9941.27719  PMID:21187887
  - 3,974 217
Guest editor's message
Pradeep Chowbey
July-September 2006, 2(3):103-103
DOI:10.4103/0972-9941.27718  PMID:21187886
  - 4,782 155
2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04