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A series of 78 laparoscopic hernioplasties performed
in the General Teaching Hospital “Enrique Cabrera.”
Objective: To
determine perioperative events, surgical complications and the evaluation of
the pain referred by the operated patients.
Methods: Between
January 2012 and December 2018, 78 hernioplasties were performed laparoscopic
in 60 patients; 18 had bilateral inguinal hernias. He collected the variables:
age, sex, type of hernia, perioperative events and complications and a pain
scale was applied. A database was filled and processed statistically.
Results:
The male sex predominated in a 5:1 ratio, the surgical time average was
53.5 min for unilateral hernias and 71.3 min for the bilateral ones. The most
frequent complication in the transoperative period was bleeding lower in 27.0%
and in the postoperative period the hematoma was in 15.3%, it recurred two
hernias (2.5%). At 15 days after surgery, 93.3% of the operated did not
complain of pain, but the social and labor reintegration was of only 34% of
patients.
Conclusion:
Laparoscopic inguinal hernioplasty is a therapeutic option more, mainly in
patients with bilateral and reproduced hernias.
Keywords: Laparoscopic hernioplasty,
Inguinal hernia, Hernia recurrence
INTRODUCTION
Since the concept of endoscopic inguinal
hernia repair was first described by Ger [1] in 1982, the endoscopic techniques
are gone modifying, going through a time when failures and complications
-united to high cost-exceeded initial enthusiasm [2]. Laparoscopic hernioplasty
(HL) has been gaining popularity in the last decade and numerous controlled
studies appear in the literature comparing the laparoscopic techniques with
conventional techniques [3-7]. In recent years, HL, despite consolidated as a
therapeutic option to consider. The advantages of this have been demonstrated
method in bilateral hernias, relapsed and in the active labor subject that
requires a precocious labor reintegration [5-7].
METHODS
Between June 2012 and June 2018, a
prospective descriptive study of longitudinal section of 60 patients operated
by hernia endoscopy of the region inguinal, in the Department of Surgery of the
General Teaching Hospital “Enrique Cabrera.”
The inclusion criteria were: Patients who
agreed with the type of surgical intervention and the study and they gave their
informed consent. Patients older than 30 years classified ASA I-III, without
contraindications anesthetics for laparoscopic interventions. Patients
classified as Nyhus III and IV. Exclusion criteria: Patients with previous
surgical wounds in the inguinal region to operate, not dependent on inguinal
hernias reproduced. Inguinal hernias complicated, irreducible or slipped.
The surgical techniques were: laparoscopic
inguinal hernioplasty completely extraperitoneal (TEP) of total
extra-peritoneal English and inguinal hernioplasty
laparoscopic
In the immediate postoperative period, the
scale of visual pain analog scale was applied (VAS) [9] and a value was
assigned to pain through “caritas”, which starts very cheerful (value I) until
very sad (value X). The quantification of pain was repeated in consultation at
7, 15 days and one month after surgery.
RESULTS
There were operated 78 hernias in 60 patients
(18 patients (30.0%) suffered from bilateral hernias, 69 primary hernias and 9
reproduced hernias). The average of age was 55.6 years, the youngest patient
was 30 years and the oldest was 77 years, but the majority (12 patients) was in
the fifth decade of life. The male sex predominated in 82.9%, which represented
a relationship man/woman of 5:1. 42.9% of patients performed large efforts
habitual physicists.
73 PET (93.6%) and 5 TAPP (6.4%) were
performed. Two of the patients in whom a TEP technique was started were
converted to a conventional prosthetic technique by accidental perforation of
the peritoneum, passing the CO2 into the peritoneal cavity and
consequently, the loss of the preperitoneal surgical space. Of the 5 TAPP
repairs, 3 of them were in the course of a laparoscopic cholecystectomy and
another was the conversion of a failed PET technique. The average surgical time
of unilateral hernias was 53.5 min, with a minimum of 25 min and a maximum of
120 min. In bilateral repairs, the average surgical time was 71.3 min and a minimum
of 40 and a maximum was observed. Of 110 min, the hospital stay was less than
24 h in 50 patients (71.4%), in 5 it extended from 24 to 48 h and in 5 to more
than 48 h. The most frequent complication in the transoperative period (Table 3) was minor bleeding in 21
repairs (27.0%) that gave rise to 12 hematomas (15.3%). No complications were
observed after the second week, but two patients suffered recurrences (2.5%),
more than two months after surgery.
The
application and evaluation of the VAS scale is shown in Table 4. In the immediate postoperative period, after the patient
recovered from anesthesia, 56 individuals (93.3%) were classified as VAS I and
4 as VAS II. Twenty-four hours after surgery, 14 patients (23.3%) were
classified as VAS I, 40 (66.6%) as VASII, 4 patients as VAS III and 2 VAS IV.
In the consultation of the first week of postoperatively, 42 patients (70.0%)
were classified as VAS I and [10] as VAS II, and two patients with moderate pain
(VAS V) appeared in this period. Fifteen days after surgery, 56 individuals
(93.3%) were VAS I and a month were 58 (96.6%). The incorporation to the usual
activities, including work, was 3 patients a week after surgery, at 15 days
they were 19 patients (31.6%) and 54 patients a month (90.0%).
DISCUSSION AND
CONCLUSION
Currently, with the improvement of
laparoscopic techniques, these are outlined as safe, reproducible and as a
therapeutic option regardless of the age of the patient; nevertheless, the
evaluation of the individual must be correct and meticulous in the preoperative
period, specifically cardiorespiratory function, since with the TEP method a
working space is created between the sheets of the cross-section sheet, richly
vascularized, so that absorption and elimination of CO2 is greater
than that produced in the peritoneal cavity during the performance of the
pneumoperitoneum [10]. Although men predominated, there was a slight increase
in women in the series with respect to other authors [3-5], which could have
been due to the inclusion in the study of 3 women who underwent the diagnosis
of inguinal hernia, in the course of a laparoscopic cholecystectomy. In
laparoscopic practice, it is not uncommon finding of hernia defects diagnosed
in the transoperative, in men and women, the latter basically with a history of
gynecological disorders. Although the usefulness of hernia repairs in
asymptomatic patients is questioned in some articles [11,12], the authors
consider that it would be beneficial for the patient, if conditions permit, the
repair of the hernia defect by the TAPP method. The relationship between the
hernia disease and the physical efforts, is classic from the Cooper era [1]. In
the series, 68% of the patients performed physical activities involving large
and medium efforts, and also analyzing the multifactorial character in the
pathogenesis of hernia disease, was striking, that approximately half of the
patients operated on were smokers, a factor that influences the metabolism of
collagen, significantly linked to hernia recurrences [13].
The majority of the repairs were by means of
the PET technique and we consider, as other authors [10,14-19] that although
the TAPP technique brings us closer to the area from a family perspective to
the surgeon (peritoneal cavity) and facilitates the so-called “learning curve”,
the hernial disease - considering it a parietal defect - should be given
solution from this same plane to avoid the likelihood of serious complications
of intra-abdominal and to leave the transperitoneal method as a tactical
resource when the totally extraperitoneal method is unsuccessful. The average
surgical time was similar to other series [3-6]. It is known that this tends to
decrease when the surgical team gains experience [16]. The largest surgical
time recorded was in a patient, who was started with a PET technique, but due
to technical difficulties, it was converted to a conventional posterior repair.
The fundamental complications were in relation to minor bleeding in the
transoperative period and postoperative hematomas. In 3 patients it was
necessary to drain the hematoma due to the discomfort caused, however, in the
rest of the patients with hematomas and seromas they were treated with
conservative measures. In two patients, the recurrence occurred 2 months after
surgery, which was interpreted as a technical error. Our results coincide with
numerous studies [3-7] that indicate the least postoperative pain of the
minimum access techniques, as well as a prompt social and labor reincorporation
of the patients. Despite the fact that 70% and 93.3% a week and 15 days
postoperatively, respectively, had no pain or discomfort were minimal, only 18
individuals (30%) were incorporated into their usual activities before 15 days.
These results contrast with other studies that report a return to work and
social activities between 10-15 postoperative days [4-17] although it is likely
that some sociocultural factors are influencing these results. It can be
concluded by noting that laparoscopic inguinal hernioplasty is another
therapeutic option, mainly in patients with bilateral and reproduced hernias.
In the series there were no major transoperative or postoperative
complications, only minor bleeding and bruising were present. Most patients
were not afflicted by pain 2 weeks postoperatively, however, return to social
and labor activities after 15 days was low [18-20].
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Table 1 -
Table 2
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Table 3
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Table 4
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