成人鼠径ヘルニアに対する

Objective
In Japan, laparoscopic inguinal herniorrhaphy(LH) is
not popular.
We performed a retrospective study to evaluate the
results of LH in our hospital.
Patients
Between August 1992 and February 2008, 286 patients
with 315 hernias were operated on at our department.
Standard method of LH in our hospital
Transabdominal preperitoneal approach
Veress needle is inserted via umbilicus
Trocar size
umbilicus:5mm right:5mm left:3mm
2
1
3
1.umbilicus
2.right flank
3.left flank
Umbilicus：30°laparoscope
Right：scissors, forceps, needle holder
introduction of mesh and tacker
Left：forceps
Mesh：polyester or polypropylene soft
（average size:14×9cm）
The advantage-1
1. Improved cosmesis
LH
Postoperative
7 months
Open repair
Postoperative
2 years
The advantage-2
2. Less postoperative pain
Earlier return to normal activity
Less chronic postoperative pain
《meta-analysis of randomized control trial》
・less postoperative pain, more rapid return to normal activity
The EU Hernia Trialists Collaboration: Br J Surg 87:860-867, 2000
・less persisting pain
The EU Hernia Trialists Collaboration: Ann Surg 23:322-332, 2002
・lower incidence of chronic pain
Schmedt CG, et al: Surg Endosc 19:188-199, 2005
The advantage-3
3. Initial visualization of a recurrent hernia defect
（the avoidance of scar tissue dissection around the area of
the previous repair）
plug
hernia defect
hernia defect
Lt. direct hernia
after Mesh-plug repair
The advantage-4
4. Initial visualization of a combined hernia defect
rt. direct hernia
rt. indirect hernia
Rt. combined hernia
The advantage-5
5. No additional incision to treat bilateral hernias
《 prospective randomized controlled clinical study 》
With relation to open tension-free repair
・higher cost
・less postoperative pain
・earlier return to work
Sarli L.et al.: Surg Laparosc Endosc Percutan Tech 11:262-267, 2001
The advantage-6
6. Evaluation of incarcerated hernia（in TAPP）
hernia defect
hernia defect
ovary
small bowel
Rt. femoral hernia
uterine tube
Rt. indirect hernia
The advantage-7
7. Diagnosis of unsuspected contralateral hernia（in TAPP）
※In our practice, it is 3.8%（11/286）.
・The reported laparoscopically detected incidence of
occult contralateral hernias is between 11.2% and 50%.
Koehler RH.: Surg Endosc 16:512-520, 2002
The disadvantage-1
1. Increased operative cost（general anesthesia, equipment）
But
・The total cost for working patients are lower with the
laparoscopic technique, when the cost of lost work days
is factored into overall expense.
Heikkinen T. et al: Surg Endosc 12:1199-1203, 1998
・From a societal perspective, laparoscopic approach can
be a cost-effective treatment option for inguinal hernia
repair.
Stylopoulos N. et al: Surg Endosc 17:180-189, 2003
The disadvantage-2
2. Specific training and long learning curve
Learning curve is
・30–50 cases
DeTurris SV. et al: J Am Coll Surg 194:65-73, 2002
・40 procedures
Lim M. et al: Surg Endosc 20:1453-1459, 2006
※ Some authors have quantified the LH learning curve
at 30–250 hernia repairs.
The disadvantage-3
3. Major complications and recurrences during the learning
curve
※We experienced two severe complications.
（one bladder injury and one trocar site hernia）
〔 Reported serious complications 〕
・visceral injury (bladder, intestine, etc.）
・vascular injury （iliac artery, etc.）
・ trocar site hernia
・ bowel obstruction
・ testicular ischemia
・ nerve injury （genitofemoral nerve, etc.）
Conclusions
1. Laparoscopic herniorrhaphy has many advantages
for both experienced surgeons and patients.
2. The widespread adoption of laparoscopic
herniorrhaphy needs cost saving and surgeon’s
technical skill.

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