Surgical procedure

Femoral herniorrhaphy was routinely started with totally extraperitoneal (TEP) repair, independent of the presence of previous abdominal operations or hernia recurrence. The procedure was previously described 9 . Briefly, carbon dioxide (CO2) was initially insufflated into the preperitoneal space immediately superior to the pubic symphysis (Space of Retzius) through a Veress needle inserted into the midline just above the pubis. Three trocars (a 10-mm infraumbilical, a 5-mm left-flank, and a 10-mm right-flank trocar) were introduced with no balloon dissector. A 15×15 cm polypropylene mesh was placed into the preperitoneal space. A 3 cm slit was made in the mesh to encircle either the round ligament or the spermatic cord. In most patients the mesh was secured on the posterior aspect of the abdominal wall by intra-abdominal pressure alone, with no fixation (sutureless). However, in patients with large hernia, tacks were employed to fix the mesh.

In patients in which it was impossible to complete the operation with the TEP procedure due to technical difficulties, the TAPP (transabdominal preperitoneal) procedure or open herniorrhaphy was employed.

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A single intravenous dose of cephazolin 2 g was given at anesthesia induction. Enoxaparin sodium 40 mg was also injected subcutaneously at anesthesia induction in patients >50 years of age, obesity (BMI >30 kg/m2), malignant tumor or presence of other risk conditions.

Immediately prior to wound incision for trocar insertion, all abdominal layers at the trocar sites were infiltrated with local anesthetic (bupivacaine hydrochloride 0.5%). The patients received a single intraoperative dose of intravenous parecoxib sodium 40 mg, tramadol hydrochloride 100 mg, and dipyrone 2 g for analgesia. A single dose of 4 mg of ondansetron was also administered intravenously prior to completion of the procedure to prevent postoperative nausea and vomiting. Liquid diet was started as soon as the patient was fully awakened and had no nausea and vomiting, usually 3-4 h after the operation. Normal diet was advanced as tolerated. No gastric tube or urinary catheter was used routinely.

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The following data were obtained and analyzed: age, gender, history of prior groin herniorrhaphy, American Society of Anesthesiology score (ASA), operative findings, surgical technique, duration of operation, intra and postoperative complications, length of hospital stay, hospital readmission and hernia recurrence. Indications for conversion to either transabdominal preperitoneal (TAPP) repair or open herniorrhaphy were also analyzed.

Patients were discharged on the same day of the operation with orientation to return to normal diet and activity as soon as tolerated. Lifting weight was limited to 10 kg in the first month after surgery. Patients returned for ambulatory follow-up on the 7th day, and one and three months after operation. Follow-up was extended as needed in presence of clinical manifestations, complications, or hernia recurrence. Values are expressed as mean ± standard deviation.

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