Reduced acute phase response after laparoscopic total extraperitoneal bilateral hernia repair compared to open repair with the Stoppa procedure.
BACKGROUND
Although laparoscopic hernia repair has been shown to be associated with less postoperative pain and an earlier recovery, there is still controversy about its role in hernia surgery. In general, laparoscopy produces less trauma to tissues than open surgery. This has been reflected by the reduced acute phase inflammatory response observed after laparoscopic surgery compared to open surgery in various settings, such as cholecystectomy or hysterectomy. The aim of this study was to evaluate the acute phase response after bilateral hernia repair by comparing the open Stoppa procedure with the laparoscopic totally extraperitoneal prosthetic repair (TEPP).


METHODS
Patients were randomly allocated to either technique after written informed consent was obtained. Measurements were made of complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-1b (IL-1b), IL-6, and tumor necrosis factor-a (TNF-a) preoperatively and 4, 24, and 48 h postoperatively. VAS pain scores, consumption of analgesics, and delay before resumption of normal activities were also recorded. All the procedures were performed under general anesthesia by or in the presence of the same surgeon.


RESULTS
Thirty-nine patients were included: 19 underwent the Stoppa procedure and 20 had a laparoscopic repair. The two groups were well matched for age, sex, ASA score, and preoperative values. The operation took longer (p <0.001) in the group undergoing TEPP. Patients resumed their normal activities earlier (p <0.05) after laparoscopy. In the open group, there was a larger decrease of the lymphocyte count after 4 (p <0.01) and 24 h (p = 0.04); an increased elevation of ESR after 48 h (p = 0.02); a larger increase of IL-6 after 4 (p = 0.05), 24 (p = 0.003), and 48 h (p <0.001); and a larger increase in CRP after 24 (p = 0.05) and 48 h (p = 0.01). There was no morbidity. There was no difference in postoperative IL-1b, TNF-a, total white blood cell count, polymorphonuclear count, VAS for pain, or need for analgesics between the two groups, except on the operative day.


CONCLUSIONS
The acute phase inflammatory response in clearly more active after the open Stoppa procedure than after TEPP, indicating that the former is associated with increased tissue trauma. This may play a role in the earlier recovery seen after the TEPP procedure.
Suter
M
M
Department of Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland. michelsuter@span.ch
Martinet
O
O
Spertini
F
F
D000210:Acute-Phase Reaction / Q000276:immunology*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002097:C-Reactive Protein; D016022:Case-Control Studies; D016207:Cytokines / Q000097:blood; D005260:Female; D059685:Herniorrhaphy; D006801:Humans; D015850:Interleukin-6 / Q000097:blood; D010535:Laparoscopy / Q000009:adverse effects*; D007902:Length of Stay; D007958:Leukocyte Count; D018655:Lymphocyte Count; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures; D010147:Pain Measurement; D010149:Postoperative Pain / Q000209:etiology; D011446:Prospective Studies; D013526:Surgical Mesh
D016207:Cytokines; D015850:Interleukin-6; D002097:C-Reactive Protein