Faculty Bibliography

The posterior approach for groin hernia repair as popularized by Stoppa and Nyhus is one of the most solid repairs available. It requires a larger incision than the anterior approach, which has limited its use to recurrent and bilateral hernias. The endoscopic extraperitoneal herniorrhaphy (EEPH) accomplishes a similar repair via three minute incisions. This study suggests that EEPH is at least as safe and efficient as the open preperitoneal repair. Three hundred sixteen male patients underwent 405 hernia repairs by an endoscopic extraperitoneal approach. Ages ranged from 18 to 82 years old. There were 204 indirect, 182 direct, 13 pantaloon, and six femoral hernias. Eighty-nine were bilateral and 42 were recurrent. All repairs were done using polypropylene mesh. Follow-up has been achieved in 89% of patients and ranged from 7 to 50 months, with a median of 25 months. Seven patients (2.2%) required conversion to an open approach. Five recurrences have developed to date. Complications (5.7%) have included urinary retention, bladder injury, groin and/or scrotal hematoma, trocar site infection, lateral femoral cutaneous nerve neuralgia, and cardiac arrhythmia. Endoscopic extraperitoneal herniorrhaphy may provide an appropriate alternative to other methods of hernia repair when performed by experienced laparoscopists.

A retrospective review of all cholecystectomies performed at a single institution since the advent of laparoscopic cholecystectomy at that institution was undertaken. Of the 1848 cases analyzed, 1372 were completed laparoscopically. There was an increase in utilization of ERCP prior to cholecystectomy, and an increase in the number of cases being done laparoscopically for acute and gangrenous cholecystitis over the 48 months of the study. Of the 1442 cases started laparoscopically, eight technical complications were recognized, and conversion was required in five of these. Only two bile duct injuries were identified in the laparoscopic group. Data analyzed over the past 2 years of the study, when the number of surgeons performing laparoscopy remained stable, showed a decrease in both complication and conversion rates. There are no strong data to support the practice of routine intraoperative cholangiography.

Endoscopic extraperitoneal herniorrhaphy (EEPH) was utilized to repair 326 groin hernias in 249 patients over a 32-month period. Nearly one in ten of the repairs was for a recurrent hernia. Several patients had contralateral hernias diagnosed only at the time of endoscopic examination. A recurrence rate of 1.6% and an overall complication rate of 5.2% are cited. After a plateau was reached on the surgeon's learning curve, various modifications in technique were implemented. Through these modifications, EEPH has become a safe, efficient, and standardized operation that can be performed with decreasing costs to the hospital and with increasing advantages to the patient.

Increasing experience among surgeons and a proliferation of endoscopic instrumentation have allowed a greater number of intraabdominal organs to be approached laparoscopically. Procedures once delegated to standard open technique are now attempted laparoscopically with increasing success. The following case report describes the laparoscopic removal of a large segment IV liver tumor. A review of the literature shows this to be one of the most complex hepatic lesions to be removed laparoscopically to date.

Laparoscopic extraperitoneal herniorrhaphy is an alternative to the standard open inguinal herniorrhaphy. The procedure is usually done with general or epidural anesthesia and carbon dioxide (CO2) insufflation. Previously, if the peritoneum was perforated in a patient on whom epidural anesthesia was used, conversion to general anesthesia was required because of the resulting pneumoperitoneum. Eliminating CO2 insufflation from the procedure would obviate this problem. The following is a description of the first 5 reported cases of extraperitoneal endoscopic herniorrhaphy done without the need for CO2 insufflation.