Delivered by Ingenta to : unknown IP : 127.0.0.1 Wed, 24 Aug 2005 07:30:56 CASE REPORT Laparoscopic Inguinal Hernioplasty in Aviators Alon Grossman, Erez Barenboim, Bella Azaria, Yaniv Sherer, Liav Goldstein, and Joseph Korianski GROSSMAN A, BARENBOIM E, AZARIA B, SHERER Y, GOLDSTEIN L, KORIANSKI J. Laparoscopic inguinal hernioplasty in aviators. Aviat Space Environ Med 2005; 76:141–3. Repair of inguinal hernias may be performed using either open sur- gery or laparoscopic techniques. Following surgery, a 6-wk waiting period is generally recommended before a pilot returns to active duty, including flight in high-performance aircraft. A shorter waiting period would be operationally useful and may be possible following either a trans-abdominal preperitoneal (TAPP) laparoscopic technique or a to- tally extra-peritoneal (TEP) approach. In this manuscript we present the cases of four aviators who underwent inguinal hernia repair via the TEP approach and were returned to the cockpit 21 d later with no evident complications. Although this sample is small, it emphasizes the potential benefit of the TEP approach in aviators. Keywords: laparoscopy, TEP, TAPP, aviators, hernioplasty. I NGUINAL HERNIOPLASTY is the most common surgical procedure performed in Western countries (13). In the United States, 800,000 inguinal hernias were surgically corrected in 2003, most by Lichtenstein and plug hernioplasties. Of these operations, 90% involve the use of mesh prostheses and were performed on an outpatient basis (13). Open anterior mesh repairs are associated with more post-operative pain and discom- fort compared with the laparoscopic approach (1). Laparoscopic hernia repair has been developed over the past decade with promising results, although large randomized comparison studies have not yet been pub- lished (8,12). The technique has become the standard of care for bilateral inguinal hernias and recurrent hernias following anterior repair, but has been criticized for technical difficulties, cost, and a long learning curve (16,18). Most studies criticizing the use of laparoscopic surgery for inguinal hernia repair were based on the use of the trans-abdominal preperitoneal (TAPP) tech- nique (5), which penetrates the abdominal cavity, lead- ing to an increased possibility of injury to the intraperi- toneal contents (6,11). The newer totally extra- peritoneal laparoscopic (TEP) technique combines the advantages of minor access surgery and mesh rein- forcement of the groin. This approach is associated with early post-operative return to usual activities and a very low recurrence rate (15). It is unclear whether exposure to high acceleration (+Gz) in high performance aircraft increases the abso- lute risk for inguinal herniation, but fear that this might be the case restricts fighter pilots who undergo hernia repair from prompt return to the cockpit. Despite op- erational demands for quick return of aviators to full activity, including flight in high-performance aircraft, current recommendations are for a waiting period of 6 wk before return to the cockpit following inguinal her- nia repair. In this manuscript we present four cases of aviators, three of whom were military jet fighter pilots, who underwent the TEP procedure for inguinal hernia repair and were returned to the cockpit after 3 wk. We believe that this will encourage use of laparoscopic procedures for the repair of inguinal hernias in aviators in order to enable quicker return to the cockpit. Case Presentations Patient 1:A 48-yr-old Grobe instructor pilot presented with right groin pain. On physical examination a right inguinal hernia and an umbilical hernia were found. A TEP laparoscopic repair was performed. He returned to flying duty in 21 d and was followed for 180 d with no complications or recurrence. Patient 2:A 41-yr-old F-16 pilot reported to the Israeli Aeromedical Center with a sensation of left groin full- ness. On physical examination a left inguinal hernia was discovered and he underwent a TEP laparoscopic repair. He returned to military flight 21 d after the procedure and was followed for 150 d with no evidence of recurrence or other complications. Patient 3:A 40-yr-old F-16 pilot reported to the Israeli Aeromedical Center with a sensation of right groin fullness. Bilateral inguinal hernia was found on physi- cal examination and was operated on through the TEP laparoscopic approach. He was returned to flying duty after 21 d and was followed for 1100 d with no evidence of complications or recurrence. Patient 4:A 21-yr-old F-16 pilot reported to the Israeli Aeromedical Center with left groin pain, increasing on exercise. A left inguinal hernia was revealed on physi- cal examination. He was operated on through a TEP laparoscopic procedure and returned to flying duty 21 d after the procedure. Follow-up of 90 d revealed no early complications or evidence of recurrence. From the Israeli Air Force Aeromedical Center (A. Grossman, E. Barenboim, B. Azaria, Y. Sherer), the Israeli Air Force Surgeon Gen- eral’s Headquarters (L. Goldstein), and the Department of General Surgery C, Sheba Medical Center (J. Korianski), Tel Hashomer, Israel. This manuscript was received for review in July 2004. It was accepted for publication in September 2004. Address reprint requests to: Alon Grossman, M.D., Rachel Hame- shoreret 27, Petach Tikwa 49504, Israel; gross-e@zahav.net.il. Reprint & Copyright © by Aerospace Medical Association, Alexan- dria, VA. 141 Aviation, Space, and Environmental Medicine • Vol. 76, No. 2 • February 2005