Laparoscopic Hernia Repair with the Extraperitoneal Approach versus Open Hernia Repair in Pediatric Inguinal Hernia: A Systematic Review and Meta-Analysis

Objective: This systematic review and meta-analysis investigated the feasibility and effectiveness of laparoscopic hernia repair with the extraperitoneal approach in pediatric inguinal hernias. Summary Background Data: Inguinal hernia repair is the most common operation in pediatric surgical practice. Although open hernia repair (OHR) is a well-established procedure with good outcomes, studies have reported acceptable or even better outcomes of laparoscopic hernia repair with the extraperitoneal approach (LHRE). However, a meta-analysis comparing LHRE with OHR is lacking. Methods: PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) and comparative studies (prospective or retrospective). Outcomes were metachronous contralateral inguinal hernia (MCIH), hernia recurrence, surgical site infection, operation time, and hospitalization length. A meta-analysis was performed, and risk ratios (RR), weighted mean difference (WMD), and 95% confidence intervals (CI) were calculated using random-effects models. Results: Five RCTs and 21 comparative studies involving 24,479 patients were included. Lower MCIH incidence (RR: 0.11, 95% CI: 0.07 to 0.17; p < 0.00001) and a trend of shorter operation time (WMD: −11.90 min, 95% CI: −16.63 to −7.44; p < 0.00001) were found in the LHRE group. No significant differences in ipsilateral recurrence hernias, surgical site infection, and length of hospitalization were found between the groups. Conclusions: LHRE presented lower MCIH incidence and shorter operation times, with no increase in hernia recurrence, surgical site infection, or length of hospitalization. As more surgeons are increasingly becoming familiar with LHRE, LHRE would be a feasible and effective choice for pediatric inguinal hernia repair.

EP.TH.109Full cycle audit reviewing the post-operative blood transfusion rate in open hernia repairs in order to reduce the number of pre-operative Group and Save Tests required: an aid to rational resource utilisation of finite resources during the COVID-19 pandemic

Aims Open hernia repairs are common elective and emergency surgical procedures; the majority are performed without complication. A primary audit indicated pre-operative group and save could be disregarded without compromising safety. A selective group and save policy was introduced, and safety of this approach examined with a 2nd cycle audit. Methods Retrospective review of electronic patient records between October 2019 to September 2020. Cross referencing of operative and blood transfusion records performed compared to the primary audit cycle of April 2018 to March 2019. Results A total of 225 open hernia repairs including inguinal, femoral and all other abdominal wall hernias were performed during the 2nd cycle compared to 410 in the 1st cycle. Patients were ASA 1-5 including emergencies. The post-operative blood transfusion rate was reduced from 1.46% to 0% following implementation of the selective policy. The number of pre-operative group and saves obtained reduced to 117; saving £6,840.19. Conclusions This single centre full cycle audit indicates pre-operative group and save tests are unnecessary in open hernia repair. A selective group and save policy introduced for certain patient characteristics such as emergency repair, ASA ≥3 or abdominal wall reconstruction reduced the post-operative blood transfusion rate to 0%. Discontinuing mandatory pre-operative group and save is a safe approach synchronously reducing clinical and financial burden. COVID-19 has stretched already limited resources, resulting in reduced surgical services and diminished case numbers during the 2nd cycle. Therefore, rational resource utilisation with a selective group and save policy maintains patient safety during the pandemic.

The rare travellers

Hernia surgery constitutes one of the major daily operative procedures in the general surgery department. Using of mesh with tension free repair is the most widely used technique. Mesh migration and subsequent perforation account as one of the very rare complications following laparoscopic or open hernia repair. The complications following surgery present with symptoms at different time intervals and are sometimes very difficult to diagnose. We present here a couple of cases of mesh migration resulting in varied clinical symptoms and a diagnostic dilemma. With more emphasis being on non-fixation of meshes in the recent literatures, a lower clinical and diagnostic threshold should be incorporated in diagnosing such complications.

997 A Systematic Review of Hernia Repair Simulation Models

Introduction There are barriers to education in both open and laparoscopic hernia repair technique, due to the laparoscopic learning curve, as well as reduced theatre time for junior surgical trainees. This is particularly evident during the current COVID-19 pandemic. Simulation models may provide further opportunities for training in hernia repair outside of the traditional surgical apprenticeship model. Method A systematic review was carried out following PRISMA guidelines to identify and evaluate simulation models in hernia repair. Of the 865 records screened, 26 were found to be relevant. These were assessed for face, content, and construct validity, as well as attempts to assess educational impact. Results Simulation models were identified comprising of animal tissues, synthetic materials, as well as VR technology. Models were designed for instruction in repair of inguinal, umbilical, incisional and diaphragmatic hernias. 4 of the 21 laparoscopic hernia repair models described demonstrated validity across several domains, and 3 of these 4 models were part of simulation-based courses demonstrating transferability of skills learnt in simulation to the operating room. Of the 5 open hernia repair simulation models, none were found to have demonstrated an educational impact in addition to assessing validity. Conclusions Few models individually were able to demonstrate validity and educational impact. Several novel assessment tools have been developed for assessment of progress when performing simulated and real laparoscopic inguinal hernia repair. More study is required, particularly for open hernia repair, including randomized controlled trials with large sample sizes to assess the transferability of skills.

Comparison of Postoperative Pain and Analgesic Requirements Between Laparoscopic and Open Hernia Repair in Children

Background This study analyses the impact of anaesthetic blockade and intraperitoneal local anaesthetic infiltration on paediatric laparoscopic inguinal hernia repair. Method A retrospective review of paediatric laparoscopic hernia repairs versus open repairs. Anaesthetic blockade, analgesic consumption and postoperative pain scores were compared between groups. Results 155 children underwent laparoscopic repair, 150 underwent open repairs. Median age was 7.2 months (16 days–14 years) in the laparoscopic group, 6 months (17 days–13 years) in the open group. Anaesthetic blockade varied significantly; 62.7% of open cases had caudal blockade compared to 21.6% laparoscopic (p < 0.001). A subset of laparoscopic patients had peritoneal local anaesthetic infiltration. 10.1% of laparoscopic cases required recovery analgesia, compared to 1.3% of open cases (p = 0.001). Postoperative analgesic consumption was significantly higher in the laparoscopic group. Peritoneal infiltration reduced analgesic consumption in the laparoscopic group (p = 0.038). Age < 2 was associated with use of caudal (p < 0.001), which reduced analgesic consumption. Conclusions Laparoscopy was associated with increased use of recovery analgesia. Caudal reduced the need for rescue and postoperative analgesia. Intraperitoneal infiltration of local anaesthetic is associated with reduced postoperative analgesia in laparoscopy. In suitable patients undergoing laparoscopic surgery, combination caudal and peritoneal infiltration may prove a useful adjunctive analgesic strategy.

A comparative study of laparoscopic technique versus open repair for inguinal hernia

Background: The repair of inguinal hernias has seen an evolution over the past few decades and more research on the same is still underway. Though laparoscopy has gained widespread acceptance in today’s era of surgery, there is still a debate between laparoscopic and open hernia mesh repair. Methods: A randomized prospective study was conducted at a tertiary care teaching hospital to compare laparoscopic hernioplasty and Lichtenstein’s open mesh repair. The study consisted of 70 subjects with unilateral or bilateral inguinal hernia and they were randomly allocated into either group. Various parameters like duration of surgery, intra and post-operative complications, post-operative pain, recurrence, stay in the hospital and resumption of daily activities were compared.Results: Out of the 70 patients, 35 underwent laparoscopic hernioplasty and 35 underwent open hernia repair. The mean operative time for laparoscopic hernioplasty (unilateral 63.44mins, bilateral 123.80mins) was greater than open hernioplasty (unilateral 47.35mins, bilateral 90.42 mins). Post-operative complications, like wound infection, seroma formation and urinary retention were noted more in the open hernioplasty group. The mean pain score for laparoscopic hernia repair was lower than open hernia repair on postoperative day 3 and 7. The average duration of hospital stay was 3.5 days in laparoscopy group and 6 days in open group. The mean duration for resumption of daily activities was 4.8 days following laparoscopic hernioplasty and 8.1 days following open hernioplasty.Conclusions: Laparoscopic hernioplasty is more beneficial than Lichtenstein’s open hernia mesh repair as it is safer, with faster recovery, lesser post-operative complications and reduced morbidity.

A study of incidence of inguinodynia in inguinal hernias repair at a tertiary center

Background: Chronic groin pain (inguinodynia) following inguinal hernia repair is a significant, though under-reported problem. Mild pain lasting for a few days is common following mesh inguinal hernia repair. However, moderate to severe pain persisting more than 3 months after inguinal herniorrhaphy should be considered as pathological. The main aim of this study was to assess the incidence of inguinodynia in inguinal hernia repair patients at a tertiary centre.Methods: This non-randomized retrospective study was undertaken in the department of general surgery, SMIMER Hospital, Surat, Gujarat, India from August 2016 to July 2019. Total 940 patients were operated for inguinal hernia repair during this period. Out of these 940 patients, only 460 patients could be traced for clinical evaluation as Surat is an industrial city with very high percentage of migrant population and so only, they were included in the study.Results: In this study, total 460 patients were included, in which 310 patients were operated for open inguinal hernia repair and 150 patients were operated for laparoscopic hernia repair. Total 102 (22.17%) patients has developed inguinodynia out of 460 patients evaluated in this series. Incidence of inguinodynia is more in open inguinal hernia repair than laparoscopic inguinal hernia repair i.e., 24.83% versus 16.67%. Incidence of testicular complication in inguinodynia patients is more in open inguinal hernia repair and non in laparoscopic repair.Conclusions: Authors conclude that overall incidence of inguinodynia is 22.17% and incidence of inguinodynia is higher in open hernia repair in comparison to laparoscopic hernia repair (24.83% versus 16.67%). The incidence of mild inguinodynia is approximately eight times more common than severe inguinodynia.