TAPP or TEP? Population-Based Analysis of Prospective Data on 4,552 Patients Undergoing Endoscopic Inguinal Hernia Repair

Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair

BACKGROUND

An inguinal hernia occurs when part of the intestine protrudes through the abdominal muscles. In adults, this common condition is much more likely in men than in women. Inguinal hernia can be monitored by 'watchful waiting', but if symptoms persist or worsen, surgery is usually required, which can be open or laparoscopic. Laparoscopic (keyhole) repair of inguinal hernias in adults is generally performed using either the transabdominal preperitoneal (TAPP) or the totally extraperitoneal (TEP) method. Both methods include the use of mesh placed in front of the peritoneal lining of the abdominal wall, but for the TAPP technique, the abdominal cavity needs to be entered to place the mesh, and for the TEP technique, the whole procedure is done on the outside of the peritoneal lining of the abdominall wall. Whether one method is superior to the other has not been established, and there is debate about their relative benefits and harms. An advantage of TEP is its avoidance of the abdominal cavity; the downside is that it requires a steeper learning curve for clinicians. TAPP is considered simpler and makes it possible to inspect the contralateral side, but TAPP may have a higher risk of visceral injury compared to TEP. This is an update of a Cochrane review first published in 2005.

OBJECTIVES

To compare the benefits and harms of laparoscopic TAPP technique versus laparoscopic TEP technique for inguinal hernia repair in adults.

SEARCH METHODS

On 25 October 2022, the authors searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R); and Ovid Embase, for published randomised controlled trials. To identify studies in progress, we searched ClinicalTrials.gov and the WHO International Clinical Trial Registry Platform (ICTRP).

SELECTION CRITERIA

All prospective randomised, quasi-randomised, and cluster-randomised trials that compared the laparoscopic TAPP technique with the laparoscopic TEP technique for inguinal hernia repair in adults were eligible for inclusion. We included studies that involved a mix of different types of groin hernia if we could extract data for the inguinal hernias. Studies may have also included a group of participants receiving hernia repair by open surgery, but these groups were not included in our review.

DATA COLLECTION AND ANALYSIS

Both review authors independently evaluated trial eligibility, extracted data from included studies, and assessed the risk of bias in the included studies. The review's primary outcomes were serious adverse events, chronic pain (persisting for at least six months after surgery), and hernia recurrence. We also assessed a variety of secondary outcomes at perioperative, early postoperative, and late postoperative time points. We performed statistical analyses using the random-effects model, and expressed the results as odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for key outcomes as high, moderate, low or very low.

MAIN RESULTS

We included 23 studies in this review update, which randomised 1156 people to TAPP and 1110 people to TEP, all requiring repair of inguinal hernias. Study sample sizes varied from 40 to 316 participants. The vast majority of study participants were male. We judged most studies to be at 'high' or 'unclear' risk of bias. Our judgements of the certainty of the evidence were low or very low for all outcomes we assessed. There may be little to no difference between TAPP and TEP laparoscopic techniques for serious adverse events (0.4% versus 0.7%; OR 0.58, 95% CI 0.15 to 2.32, P = 0.45, I2 = 0%; 19 studies, 1735 participants; low certainty of evidence); and hernia recurrence (1.2% versus 1.1%; OR 1.14, 95% CI 0.49 to 2.62, P = 0.97, I2 = 0%; 17 studies, 1712 participants; low certainty of evidence). The evidence is very uncertain about the effects of TAPP versus TEP techniques on chronic pain (OR 0.62, 95% CI 0.20 to 1.97, P = 0.68, I2 = 0%; 6 studies, 860 participants; very low certainty of evidence). In terms of secondary outcomes, the evidence is very uncertain for TAPP versus TEP techniques for perioperative visceral and vascular injury (15 studies, 1523 participants; very low certainty of evidence), and for haematoma or seroma during the early (≤ 30 days) postoperative phase (OR 0.86, 95% CI 0.54 to 1.37, P = 0.3861, I2 = 0%; 15 studies, 1423 participants; very low certainty of evidence). TEP technique may carry a higher risk of conversion to another hernia repair method (either TAPP technique or open surgery) when compared to TAPP (2.5% versus 0.7%; OR 0.28, 95% CI 0.09 to 0.84, P = 0.02, I2 = 0%; 13 studies, 1178 participants; low certainty of evidence). Only two studies (474 participants) reported quality of life in the late (> 30 days) postoperative phase; overall, there was an improvement in quality of life from the pre- to post-operative assessment, but the evidence suggests little to no difference between the techniques (low certainty of evidence).

AUTHORS' CONCLUSIONS

This review update found that there may be little to no difference between the TAPP and TEP techniques for serious adverse events, hernia recurrence, or chronic pain (low- to very-low-certainty evidence). Decisions about which method to use will most likely reflect surgeon and patient preference until high-certainty evidence becomes available. There may be a higher risk of needing to convert from TEP to TAPP or open surgery when compared to the risk of needing to convert from TAPP to open surgery (low-certainty evidence). If surgeons opt for TEP as their standard laparoscopic method, they could consider having a strategy for how to handle the potential need for conversion. This might include proficiency in the TAPP approach or having informed the patient about the risk of conversion to open surgery. For surgeons or surgical departments, the choice of a laparoscopic technique should involve shared decision-making with patients and their families or carers. Future research could focus on patient-reported outcomes, such as quality of life.

Laparoscopic transabdominal preperitoneal herniorrhaphy performed using an articulating laparoscopic instrument is feasible and more efficient

Introduction

Ipsilateral left-sided-approach laparoscopic transabdominal preperitoneal herniorrhaphy (LA-TAPP) is a procedure used for inguinal hernia. However, conventional laparoscopic instruments may limit the operator's ability to approach certain areas during the procedure. This study aims to assess the feasibility of using an articulating bipolar grasper (ArtiSential®).

Material and methods

Between January 2017 and May 2022, 184 patients with inguinal hernia underwent LA-TAPP and were divided into an articulating group (AG) and a conventional group (CG). The two groups were compared for clinical characteristics, surgical outcomes, and recurrence rates. Learning curve analysis was also performed using the CUSUM score.

Results

The AG and CG included 72 and 112 patients, respectively. Both groups had similar age, sex, BMI, hernia location, and hernia type. The AG had a significantly shorter operation time (59.2 ± 29.4 vs. 77.8 ± 22.4 min, p < 0.001) than the CG. The duration of hospitalization was slightly shorter in the AG (2.2 ± 0.5 vs. 2.5 ± 1.4 days, p = 0.056). Postoperative complications were lower in the AG (5.6%) than in the CG (9.8%). Scrotal neuralgic pain was observed in 1.4% of patients in the AG and 3.6% of patients in the CG. Learning curve analysis revealed that 24 cases were needed to overcome the learning curve for using an articulating device.

Conclusion

IP-TAPP with an articulating instrument is a safe and efficient procedure. The operation time can be reduced by improving the surgeon's procedural autonomy and reducing collisions between the instruments and the patient's ribs.

Lichtenstein versus TIPP versus TAPP versus TEP for primary inguinal hernia, a matched propensity score study on the French Club Hernie Registry

PURPOSE

Groin hernia repair is one of the most frequent operation performed worldwide. Chronic postoperative inguinal pain (CPIP) is the most common and challenging complication after surgical repair with subsequent high socio-economic impact. The aim of this study was to compare the one-year CPIP rates between Lichtenstein, trans-inguinal pre-peritoneal (TIPP), trans-abdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP) repair techniques on the French Hernia Registry.

METHODS

Between 2011 and 2021, 15,161 primary groin hernia repairs with 1-year follow-up were available on the register. Using propensity score (PS) matching, matched pairs were formed. Each group was compared in pairs independently; Lichtenstein versus TIPP, TEP and TAPP, TIPP versus TEP and TAPP and finally TEP versus TAPP.

RESULTS

After PS matching analysis, Lichtenstein group showed disadvantage over TIPP, TAPP and TEP groups with significantly more CPIP at one year (15.2% vs 9.6%, p < 0.0001; 15.9% vs. 10.0%, p < 0.0001 and 16.1% vs. 12.4%, p = 0.002, respectively). The 1-year CPIP rates were similar comparing TIPP versus TAPP and TEP groups (9.3% vs 10.5%, p = 0.19 and 9.8% vs 11.8%, p = 0.05, respectively). There was significantly less CPIP rate after TAPP versus TEP repair (1.00% vs 11.9%, p = 0.02).

CONCLUSION

This register-based study confirms the higher CPIP risk after Lichtenstein repair compared to the pre-peritoneal repair techniques. TIPP leads to comparable CPIP rates than TAPP and TEP repairs.

Laparoscopic mesh placement during inguinal hernia repair: a meta-analysis of two methods of repair

BACKGROUND

There are several modifications in the technique for the placement of mesh during laparoscopic inguinal hernia repair. One of these is a slit on the mesh to surround the cord structures which proponents of it suggest that it decreases the recurrence rate due to better anchoring of the mesh and lower risk of displacement. There is only low-level evidence in current literature examining the two methods. The present study aimed to provide stronger evidence in establishing whether the slit mesh technique is superior to the non-slit mesh technique.

METHODS

The reporting of this systematic review was guided by the standards of the preferred reporting items for systematic review and meta-analysis statement and registered with PROSPERO (ID: CRD42022300629). Eligible studies had to compare the two methods of mesh placement slit Vs nonslit in laparoscopic Inguinal hernia repair and also report on at least one outcome. The outcomes were expressed in odd ratios with their 95% confidence intervals. Where significant heterogeneity existed a random effects model was used otherwise a fixed effects model was used.

RESULTS

Five studies met the criteria for inclusion in quantitative analysis. Overall, there were 10 (1.5%) recurrences in the slit group compared to 12 (2.5%) in the non-slit group OR 0.62, 95% CI (0.27-1.41). There was no difference in the incidence of post-operative bleeding (OR 1.21, 95%CI 0.4-3.66), seroma formation (OR1.5, 95% CI 0.81-2.76), or post-operative neuralgia (OR 0.98, 95%CI 0.11-8.92) between the two groups.

CONCLUSION

There was no difference between the two methods.

Sexual dysfunction between laparoscopic and open inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Sexual dysfunction after inguinal hernia complication is considered rare. However, its consequences impact on quality of life inevitably. Laparoscopic and open inguinal hernia repair may be comparable in terms of recurrent rate, overall complications, and chronic pain. Therefore, its complication is still questionable between these approaches. In this study, we compared sexual dysfunction and related complications between laparoscopic and open inguinal hernia repair.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) studies were performed to compare laparoscopic and open inguinal hernia repair. Risk ratio (RR) and 95% confidence intervals (95% CI) were used as pooled effect size measures.

RESULT

Thirty RCTs (12,022 patients) were included. Overall, 6014 (50.02%) underwent laparoscopic hernia repair, and 6008 (49.98%) underwent open hernia repair. Laparoscopic approach provided non-significance benefit on pain during sexual activity (RR 0.57; 95% CI 0.18, 1.76), Vas deferens injury (RR 0.46; 95% CI 0.13, 1.63), orchitis (RR 0.84; CI 0.61,1.17), scrotal hematoma (RR 0.99; CI 0.62,1.60), and testicular atrophy (RR 0.46; CI 0.17,1.20). Meanwhile, the open inguinal hernia approach seems to perform better for cord seroma complications and testicular pain.

CONCLUSION

There is no advantage of laparoscopic inguinal hernia repair over an open approach concerning sexual dysfunction. On the contrary, there is an increasing risk of cord seroma after laparoscopic inguinal hernia repair with statistical significance.

Comparison of Extended Total Extraperitoneal (E-TEP) Repair and Trans-Abdominal Pre-Peritoneal (TAPP) Mesh Repair in Inguinal Hernia Repair

BACKGROUND AND AIM

To find the superiority of extended total extraperitoneal (E-TEP) repair and trans-abdominal pre-peritoneal (TAPP) mesh repair in inguinal hernia repair.

MATERIAL AND METHODS

A total of 30 patients with a unilateral or bilateral inguinal hernia (IH), and recurrent IH, following open repair were studied. Out of 30 patients, laparoscopic TAPP or E-TEP mesh repair was performed in an equal number of inguinal hernia patients. The patient's demographic parameters, duration of surgery, postoperative hospital stay, and complications were compared.

RESULTS

 In the E-TEP group, 33.33% of patients had left inguinal hernia (LIH), 60% of patients were diagnosed with right inguinal hernia (RIH) and 6.67% of patients had right inguinal and right direct hernia (RDH). In the TAPP group, 33.33% of patients had LIH and 53.33% of patients were suffering from RIH. Moreover, 6.67% of patients were diagnosed with a left inguinal direct hernia, and a similar proportion of patients had a right inguinal direct hernia. The mean duration of surgery was found to be significantly higher in the TAPP group (P<0.0000). The mean postoperative hospital stay was 2.07±0.59 and 2.80±1.32 days in E-TEP and TAPP groups, respectively (P=0.044).

CONCLUSION

In the present study, E-TEP mesh repair is a superior technique in the management of inguinal hernia as compared with TAPP repair.

Nationwide analysis of laparoscopic groin hernia repair in Italy from 2015 to 2020

Since its introduction, the minimally invasive treatment of groin hernias has become widely accepted as a viable alternative to open surgery. Still, the rates and reasons for its adoption vary highly among countries and the regions within a country. After almost thirty years since its introduction, its spread is still limited. The present study, conducted under the auspices of AGENAS (Italian National Agency for Regional Services), aims at giving a snapshot of the spreading of minimally invasive and robotic techniques for the treatment of groin hernia in Italy. This study is retrospective, with data covering the period from 1st January 2015 to 31st December 2020. AGENAS provided data using the operation and diagnosis codes used at discharge and reported in the International Classification of Diseases 9th revision (ICD9 2002 version). Admissions performed on an outpatient basis, i.e., without an overnight stay of at least one night in hospital, were excluded. A total of 33,925 laparoscopic hernia repairs were performed during the considered period. Overall, a slight increase in the number of procedures performed was observed from 2015 to 2019, with a mean annual change of 8.60% (CI: 6.46-10.74; p < 0.0001). The number of laparoscopic procedures dropped in 2020, and when considering the whole period, the mean annual change was - 0.98% (CI: - 7.41-5.45; p < 0.0001). Urgent procedures ranged from 335 in 2015 to 508 in 2020 referring to absolute frequencies, and from 0.87% to 9.8% in relative frequencies of overall procedures in 2017 and 2020, respectively (mean = 4.51%; CI = 3.02%-6%; p < 0.001). The most relevant observation that could be made according to our analysis was that the adoption of the laparoscopic approach knew a slow but steady increase from 2015 onward.

Posterior mesh inguinal hernia repairs: a propensity score matched analysis of laparoscopic and robotic versus open approaches

PURPOSE

International guidelines suggest the use of lapro-endoscopic technique for primary unilateral inguinal hernia (IHR) because of lower postoperative pain and reduction in chronic pain. It is unclear if the primary benefit is due to the minimally invasive approach, the posterior mesh position or both. Further research evaluating posterior mesh placement using open preperitoneal techniques is recommended. A potential benefit of open preperitoneal repair is the avoidance of general anesthesia, as these repairs can be performed under local anesthesia. This study compares clinical and patient-reported outcomes after unilateral laparo-endoscopic, robotic, and open posterior mesh IHRs.

METHODS

We performed a propensity score matched analysis of patients undergoing IHR between 2012 and 2021 in the Abdominal Core Health Quality Collaborative registry. 10,409 patients underwent a unilateral IHR via a posterior approach. Hernia repairs were performed via minimally invasive surgery (MIS) which includes laparoscopic and robotic transabdominal preperitoneal (TAPP), laparoscopic totally extraperitoneal (TEP), or open transrectus preperitoneal/open preperitoneal (TREPP/OPP) approaches. Propensity score matching (PSM) utilizing nearest neighbor matching accounted for differences in baseline characteristics and possible confounding variables between groups. We matched 816 patients in the MIS cohort with 816 patients in the TREPP/OPP group. Outcomes included patient reported quality of life, hernia recurrence, and postoperative opioid use.

RESULTS

Improvement was seen after TREPP/OPP as compared to MIS IHR in EuraHS at 30 days (Median(IQR) 7.0 (2.0-16.64) vs 10 (2.0-24.0); OR 0.69 [0.55-0.85]; p = 0.001) and 6 months (1.0 (0.0-4.0) vs 2.0 (0.0-4.0); OR 0.63 [0.46-85]; p = 0.002), patient-reported opioid use at 30-day follow-up (18% vs 45% OR 0.26 [0.19-0.35]; p < 0.001), and rates of surgical site occurrences (0.8% vs 4.9% OR 0.16 [0.06-0.35]; p < 0.001). There were no differences in EuraHS scores and recurrences at 1 year.

CONCLUSIONS

This study demonstrates a potential benefit of open posterior mesh placement over MIS repair in short-term quality of life and seroma formation with equivalent rates of hernia recurrence. Further study is needed to better understand these differences and determine the reproducibility of these findings outside of high-volume specialty centers.

Extraperitoneal Laparoscopic Approach in Inguinal Hernia—The Ideal Solution?

Background: After more than 20 years since laparoscopy was proposed as a solution for one of the most common surgical pathologies, inguinal hernia, the choice of an intra- or extraperitoneal approach has remained a highly debated topic. Purpose and objectives: This study aimed at analyzing the feasibility of the extraperitoneal approach, by routine for this team/ and answering the question of whether this type of approach can be considered a safe one. Although indications for an intra- or extraperitoneal approach largely overlap, it may also be a matter of surgeon preference in choosing one technique. Methods: The study was retrospective, conducted on a group of 493 patients operated on for inguinal hernia in the clinic, by a single operating team, between January 2012 and March 2022. Results: It was proven that out of the 493 surgeries for inguinal hernia, 95.1% (n = 469) were operated upon by laparoscopic TEP (total extra peritoneal patch plasty approach); 1.62% (n = 8) by laparoscopic TAPP (transabdominal intraperitoneal); and 3.24% (n = 16) by the open, anterior approach (Lichtenstein). There were no intraoperative complications recorded in any of the procedures, while postoperative complications were found in 10.23% of cases (n = 48) in the extraperitoneal approach, and recurrences after the TEP approach were recorded in 0.40% of cases (n = 2). Conclusions: For correctly selected cases, TEP hernia surgery can be considered a safe and reliable approach.

Lichtenstein and Total Extraperitoneal Techniques in Inguinal Hernia Surgery: A Comparison of the Intraoperative and Early Postoperative Complications Between the Two Approaches

Background and objective

The Lichtenstein technique (LSt) and total extraperitoneal technique (TEPt) are the most frequently performed surgical procedures for inguinal hernia (IH). This study aimed to compare LSt and TEPt in terms of intraoperative and postoperative complications as well as recurrence rates.

Methods

This retrospective study involved patients hospitalized for IH repair. The study included a total of 262 patients (LSt group: n=125; TEPt group: n=137). 

Results

The follow-up period of the patients ranged between 16 and 30 months (mean: 22.3 months). While intraoperative complications were more commonly reported in the TEPt group, postoperative complications were more common in the LSt group (2.9% vs. 1.6%). Postoperative bleeding/hematoma developed in three (2.4%) patients in the LSt and three (2.2%) in the TEPt group. One of the patients in the LSt group was reoperated due to persistent bleeding. Two patients in the LSt and two in the TEPt group were reoperated for postoperative recurrence (1.6% vs. 2.4%). One patient was reoperated due to chronic persistent pain. Seroma was aspirated in three (2.4%) patients in the LSt and two (1.5%) in the TEPt group.

Conclusion

This study revealed no significant difference between TEPt and LSt groups regarding intraoperative and postoperative complications. We propose that both TEPt and LSt could be safely performed in cases of primary and complex IH by selecting the appropriate method based on the hernia type and patient and with sufficient surgical experience.

Learning curve of single-incision laparoscopic totally extraperitoneal repair (SILTEP) for inguinal hernia

PURPOSE

Laparoscopic totally extraperitoneal hernia repair (TEP) is a widely used treatment for inguinal hernia. Single-incision laparoscopic TEP (SILTEP) has attracted the attention of several surgeons, given its superior cosmetic results and patient satisfaction, as well as comparable outcomes to multiport surgery. Nonetheless, no relevant studies have evaluated the learning curve (LC) of SILTEP in terms of both operation time (OT) and surgical failure. Therefore, we aimed to investigate the LC of SILTEP for inguinal hernia.

METHODS

Medical records of 180 patients who underwent SILTEP performed by a single surgeon from a single institution between October 2012 and November 2017 were retrospectively reviewed. The LC was analyzed using the moving average method and cumulative sum control chart (CUSUM) for OT and surgical failure. Surgical failure was defined as the need for additional ports, open conversion, severe postoperative complications (Clavien-Dindo ≥ IIIa), and recurrence. Eight patients who underwent combined surgery or bilateral hernia repair were excluded from the OT analysis.

RESULTS

From CUSUM graphs, the study period was divided into three phases: OT-phases 1 (1st-32nd), 2 (33rd-83rd), and 3 (84th-172nd) for OT and failure-phases 1 (1st-29th), 2 (30th-58th), and 3 (59th-180th) for surgical failure. Mean OTs were statistically different in the three OT phases (64.6 vs. 50.8 vs. 35.2 min; p < 0.001). Open conversion (31.0% vs. 0% vs. 2.5%) and additional port insertion (6.9% vs. 24.1% vs. 2.5%) stabilized consecutively at failure-phases 2 and 3 (p < 0.001). Surgical failure rates decreased to 5.7% by failure-phase 3 (37.9% vs. 24.1% vs. 5.7%; p < 0.001).

CONCLUSION

For an experienced laparoscopic surgeon, we estimated that approximately 60 cases are needed to overcome the LC for SILTEP in terms of both reducing OT and achieving a surgical failure rate < 10%. Further proficiency could be achieved after approximately 85 SILTEP procedures with a stable OT of approximately 35 min.

Pain After Transabdominal Preperitoneal (TAPP) or Totally Extraperitoneal (TEP) Technique for Unilateral Inguinal Hernia: A Randomized Controlled Trial

Introduction

Laparoscopic inguinal hernia repair is the most commonly performed surgery in many hospitals. This study aimed to compare the outcome of the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques in unilateral, uncomplicated inguinal Hernia.

Material and methods

This prospective randomized study was conducted in a tertiary care hospital in North India from November 2018 to March 2020. Sixty-eight male patients of unilateral, uncomplicated inguinal hernia were enrolled for laparoscopic hernia repair. The first group of 34 patients underwent TAPP repair and the second group of 34 patients underwent TEP repair under general anesthesia (GA). Both groups were compared for intraoperative or postoperative complications, analgesic requirements, postoperative pain, length of hospital stay, resumption of routine activity, and patient satisfaction scores. Fisher's exact test or Chi-square test were used for nominal data and the median or interquartile range was used for ordinal data.

Results

The mean operative time for TAPP was more than that for the TEP group (101 vs 76, p<0.001). The TAPP group exhibited significantly less postoperative pain at six hours, 24 hours and seven days than TEP (p<0.001) and an insignificant difference at three months of the follow-up period (p=0.188). Additional analgesics requirement was less in the TAPP group, although the difference was not significant (p=0.099). Seroma formation was found in four patients (11.8%) in the TEP group and two patients (5.9%) in the TAPP group (p= 0.672). Length of postoperative hospital stay (p=0.907), resumption of routine activity (p=0.732), and patient satisfaction scores (p=0.492) during follow-up were similar in both groups and were also insignificant.

Conclusion

The TAPP technique is slightly better than TEP for inguinal hernia in terms of lesser postoperative pain with similar chances of complications and other outcomes.

Hydrocele of the Canal of Nuck: A Review

Canal of Nuck abnormality is a rare surgical condition. The pathologies are mostly encountered in young girls, less than five years of age. The incidence is even less in adults. Various pathologic conditions related to the failure of processus vaginalis obliteration can occur, involving herniation of intraabdominal structures including intestinal and genital contents such as the uterus, fallopian tube, and ovary and hydrocele of the canal of Nuck.

According to its rarity, hydrocele of canal of Nuck is often misdiagnosed for common groin masses. This review summarizes and simplifies embryology, the pathophysiology of the canal of Nuck abnormalities, imaging findings, and treatment options with emphasis on the hydrocele. 

Laparoscopic transabdominal preperitoneal and totally extraperitoneal in inguinal hernia surgery: comparison of intraoperative and postoperative early complications of two techniques

Purpose

Methods

Results

Conclusion

Outcomes of 207 totally extraperitoneal hernia repairs using self-fixation mesh

Inguinal hernia (IH) repair is one of the most common procedures in general surgery around the world. Minimizing postoperative acute and chronic pain without increasing recurrence has been a critical point, giving place to different strategies like self-fixation mesh. The current study aimed to describe a group of patients who underwent IH repair by Totally Extraperitoneal (TEP) technique with self-gripping mesh at a fourth level hospital between 2012 and 2019. Retrospective review of a prospectively collected database including patients who underwent laparoscopic TEP approach with self-fixation mesh for IH repair. Follow up data was obtained at 12, 24, 36, 48, and 60 months post surgical intervention. 207 hernia repairs were performed in 142 patients, with a total of 66 patients with bilateral IH. 10.6% required hospitalization due to either concomitant procedure performed or cardiovascular comorbidities, with a mean hospital stay of 1.6 days. Median and late follow up was up to 5 years. 88.9% of patients complete a year, 86% two years, and 36.7% with a 5 year follow-up. IH repair using the TEP technique and self-fixation mesh showed to be an excellent approach, demonstrating satisfactory results in follow up and complications.

Hydroceles of the Canal of Nuck in Adults-Diagnostic, Treatment and Results of a Rare Condition in Females

Nuck’s hydroceles, which develop in a protruding part of the parietal peritoneum into the female inguinal canal, are rare abnormalities and a cause of inguinal swelling, mostly resulting in pain. They appear when this evagination of the parietal peritoneum into the inguinal canal fails to obliterate. Our review of the literature on this topic included several case reports and two case series that presented cases of Nuck hydroceles which underwent surgical therapy. We present six consecutive cases of symptomatic hydroceles of Nuck’s canal from September 2016 to January 2020 at the Department of Surgery of Charité Berlin. Several of these patients had a long history of pain and consecutive consultations to outpatient clinics without diagnosis. These patients underwent laparoscopic or conventional excision and if needed simultaneous hernioplasty in our institution. Ultrasonography and/or Magnetic Resonance Imaging were used to display the cystic lesion in the inguinal area, providing the diagnosis of Nuck’s hydrocele. This finding was confirmed intraoperatively and by histopathological review. Ultrasound and magnetic resonance imaging (MRI) captures, intraoperative pictures and video of minimal invasive treatment are provided. Nuck’s hydroceles should be included in the differential diagnosis of an inguinal swelling. We recommend an open approach to external Type 1 Nuck´s hydroceles and a laparoscopic approach to intra-abdominal Type 2 Nuck hydroceles. Complex hydroceles like Type 3 have to be evaluated individually, as they are challenging and the surgical outcome is dependent on the surgeon’s skills. If inguinal channel has been widened by the presence of a Nuck’s hydrocele, a mesh plasty, as performed in hernia surgery, should be considered.

Totally Extraperitoneal Repair in Inguinal Hernia: More Than a Decade's Experience at a Tertiary Care Hospital

INTRODUCTION

There are 2 standard techniques of laparoscopic groin hernia repair, totally extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP). TEP has the advantage that the peritoneal cavity is not breached but is, however, considered to be more difficult to master when compared with TAPP. We describe herein our experience of TEP repair of inguinal hernia over the last 14 years.

MATERIALS AND METHODS

This study is a retrospective analysis of a prospectively maintained database of all patients with groin hernia who underwent TEP repair in a single surgical unit between January 2004 and January 2018. Patients' demographic profile and hernia characteristics (duration, side, extent, content, and reducibility) were noted in the prestructured proforma. Clinical outcomes included the operation time, intraoperative and postoperative complications, length of postoperative hospital stay, hernia recurrence, chronic pain, recurrence, seroma, and wound infections. Long-term follow-up was carried out in the outpatient department.

RESULTS

Over the last 14 years, TEP repair was performed in 841 patients and a total of 1249 hernias were repaired. The mean age of patients was 50.7 years. There were 748 primary and 345 unilateral hernias. The majority were direct (61%) inguinal hernias. Telescopic dissection was the commonest method of space creation. The average operating time was 54.8 and 77.9 minutes for unilateral and bilateral hernias, respectively. With 81 conversions, the success rate for TEP was 93.5%. Seroma was the most common postoperative complication seen in 81 patients. The incidence of chronic groin pain was 1.4%. The follow-up ranged from 3 months to 10 years, and there were only 3 recurrences (<1%).

CONCLUSION

In conclusion, TEP repair is an excellent technique of laparoscopic inguinal hernia repair with acceptable complications after long-term follow-up.

Mesh fixation technique in totally extraperitoneal inguinal hernia repair - A network meta-analysis

Laparoscopic totally extra-peritoneal inguinal hernia repair is the standard option for inguinal hernia treatment. However, there are various types of mesh fixation and their relative uses are still controversial. This network meta-analysis was conducted to compare and rank the different fixations available for TEP. Medline and Scopus databases were search until February 1, 2017 and using randomized controlled trials comparing outcomes between different mesh fixation techniques were included. The results demonstrated that fifteen RCTs (n = 1783) were eligible for pooling. Five types of mesh fixation were used; metallic tack, no-fixation, absorbable tack, suture, and glue. Network meta-analysis that use metallic tack as the reference, indicated that suture and glue both carried a lower risk of recurrence with pooled risk ratios (RR) of 0.29 (95% CI 0.00, 18.81) and 0.29 (0.07, 1.30), respectively. For overall complications, absorbable tack had lower risk (0.63, 95% CI: 0.02, 16.13). However, none of these estimates reached statistical significance. So, this network meta-analysis suggests that glue and absorbable tack might be best in lowering recurrence risk and complications. However, a large scale RCT is still needed to confirm these results.

[Endoscopic surgery and laparoscopy are new insights of evolution of inguinal hernia repair (in Russian only)]

This article is devoted to general and particular problems of inguinal hernia repair through the analysis of statistical data and comparison of advantages and disadvantages of various methods of inguinal hernia repair. Particular attention is paid to the analysis of current options of mesh implant fixing during endoscopic hernia repair: TAPP, TER, e-TER. Long-term outcomes are essential to determine surgical technique. The authors consider that careful adherence to the basic principles of minimally invasive surgery can reduce the incidence of complications, recurrences and chronic pain syndrome after inguinal hernia repair. The main advantages of current surgical technologies are accelerated rehabilitation, earlier restoration of social activity, improvement of the quality of life.

Primary unilateral not complicated inguinal hernia: our choice of TAPP, why, results and review of literature

BACKGROUND

Currently, three different techniques are favored for repair of an inguinal hernia: (1) The suture repair described by Shouldice. (2) An open mesh repair according to Lichtenstein. (3) Laparo-endoscopic techniques TAPP and TEP. The aim of the presented paper was to describe the ranking of the Transabdominal Preperitoneal Patch Plasty (TAPP) in comparison to the other techniques for inguinal hernia repair.

METHODS

The manuscript is based on the experiences gained in more than 15,000 TAPPs and numerous own studies as well. The technique of TAPP is described in detail and also the results which can be achieved with special reference to primary unilateral inguinal hernias in male patients. Moreover, a systematic review of the literature is done for the comparison with the other techniques.

RESULTS

According to own experiences, 98% of all patients with an inguinal hernia admitted for surgery to Marienhospital Stuttgart could be operated on using the TAPP technique. The recurrence rate and the rate of severe chronic pain in this setting were below 1%. Due to the limited quality of most of the published studies an evidence-based comparison which is the best of the currently most recommended techniques is questionable. Therefore, when comparing TAPP with TEP, no definite conclusion about superiority of one technique over the other is possible. Both techniques are safe and effective if properly performed. The guidelines recommend that the surgeon should use the technique he had learned best and is familiar with. The comparison between TAPP and the Shouldice repair shows less pain and a higher effectivity after TAPP. The recurrence rate after Lichtenstein repair and after TAPP is similar, but pain and recovery time are significantly less after TAPP.

CONCLUSION

Analyzing the own abundant experiences and the reports in the literature, the TAPP technique has the potential to become the standard operative technique for repair of inguinal hernias in future. However, due to the low level of evidence of most of the studies definite conclusions are difficult to draw at this point of time.

Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair in patients with previous lower abdominal surgery

BACKGROUND

We have performed laparoscopic totally extraperitoneal (TEP) repair for inguinal hernia repair for the last 20 years. We use two balloon dilators (sphere and kidney type) to dissect the preperitoneal space for the TEP repair. It may be difficult to obtain exposure in patients who previously underwent lower abdominal surgery, because of adhesions to the abdominal wall. We reviewed our experience with inguinal hernia repairs to retrospectively analyze factors that limit the laparoscopic TEP approach.

METHODS

From 2006 to 2016, 313 patients (281 men and 32 women) underwent laparoscopic TEP inguinal hernia repair at Yuki Hospital. The medical records of these patients were reviewed, and data for patients who previously underwent lower abdominal surgery were analyzed.

RESULTS

Eighty-four patients previously underwent lower abdominal surgery including appendectomy (N = 23), inguinal hernia repair [N = 45; including contralateral TEP repair (N = 26), ipsilateral anterior approach (N = 11)], and laparotomy with a lower abdominal midline incision (N = 22). TEP repair was successfully completed in 75 patients (75/84; 89%) and the procedure changed in nine patients to an anterior approach (N = 5), or transabdominal preperitoneal (TAPP) repair (N = 4). The reasons for changing the procedure included difficulty to develop the operative field (N = 5), violation of the integrity of the peritoneal envelope (N = 2), and intraoperative bleeding (N = 2). Seven patients had a contralateral inguinal hernia after TEP repair.

CONCLUSION

The majority of patients with an inguinal hernia and previous lower abdominal surgery underwent successful laparoscopic TEP repair. There is no need to avoid the laparoscopic TEP approach, even in patients with a history of previous lower abdominal surgery. However, patients after TEP repair of a contralateral inguinal hernia may be at increased risk for peritoneal injury and the approach may need to be changed.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

TAPP or TEP for Recurrent Inguinal Hernia? Population-Based Analysis of Prospective Data on 1309 Patients Undergoing Endoscopic Repair for Recurrent Inguinal Hernia

BACKGROUND

Whether total extraperitoneal inguinal hernia repair (TEP) is associated with worse outcomes compared to transabdominal preperitoneal inguinal hernia repair (TAPP) for the treatment of recurrent inguinal hernia continues to be a matter of debate. The objective of this large cohort study is to compare complications, conversion rates and postoperative length of hospital stay between patients undergoing TEP or TAPP for unilateral recurrent inguinal hernia repair.

METHOD

Based on prospective data of the Swiss Association of Laparoscopic and Thoracoscopic Surgery, all patients who underwent elective TEP or TAPP for unilateral recurrent inguinal hernia between 1995 and 2006 were included. The following outcomes were compared: conversion rates, intraoperative complications, surgical postoperative complications and duration of operation.

RESULTS

Data on 1309 patients undergoing TEP (n = 1022) and TAPP (n = 287) for recurrent inguinal hernia were prospectively collected. Average age, BMI and ASA score were similar in both groups. Patients undergoing TEP had a significantly increased rate of intraoperative complications (TEP 6.3 % vs. TAPP 2.8 %, p = 0.0225). Duration of operation was longer for patients undergoing TEP (TEP 80.3 vs. TAPP 73.0 min, p < 0.0023) while postoperative length of hospital stay was longer for patients undergoing TAPP (TEP 2.6 vs. TAPP 3.1 day, p = 0.0145). Surgical postoperative complications (TEP 3.52 % vs. TAPP 2.09 %, p = 0.2239), general postoperative complications (TEP 1.47 % vs. TAPP 0.7 %, p = 0.3081) and conversion rates (TEP 2.15 % vs. TAPP 1.39 %, p = 0.4155) were not significantly different.

CONCLUSION

This study is the first population-based analysis comparing outcomes of patients with recurrent inguinal hernia undergoing TEP versus TAPP in a prospective cohort of over 1300 patients. Intraoperative complications were significantly higher in patients undergoing TEP. The TEP technique was associated with longer operating times, but a shorter postoperative length of hospital stay. Nonetheless, the absolute outcome differences are small and thus, on a population-based level, both techniques appear to be safe and effective for patients undergoing endoscopic repair for unilateral recurrent inguinal hernia.

Laparoscopic Total Extraperitoneal Hernia Repair Outcomes

Background and Objectives:

Laparoscopic inguinal hernia repair has become increasingly popular as an alternative to open surgery. The purpose of this study was to evaluate the safety and effectiveness of the laparoscopic total extraperitoneal procedure with the use of staple fixation and polypropylene mesh.

Methods:

A retrospective chart review examined outcomes of 1240 laparoscopic hernia operations in 783 patients, focusing on intraoperative and early postoperative complications, pain, and time until return to work and normal physical activities.

Results:

There were no intraoperative complications in this series; 106 patients experienced early postoperative complications across 8 evaluated categories: urinary retention (4.1%), seroma (3.0%), testicular/hemiscrotal swelling (1.9%), testicular atrophy (0%), hydrocele (0.6%), mesh infection (0.1%), and neurological symptoms (transient, 1.0%; persistent, 0.2%). Patients used an average of 5.6 Percocet pills after the procedure, and mean times until return to work and normal activities, including their routine exercise regimen, were 3.0 and 3.8 days, respectively.

Conclusion:

Complication rates and convalescence times were considered equivalent or superior to those found in other studies assessing both laparoscopic and open techniques. The usage of multiple Endostaples did not result in increased neurologic complications in the early postoperative period when compared with findings in the literature. In the hands of an experienced surgeon, total extraperitoneal repair is a safe, effective alternative to open inguinal hernia repair.

Risk factors for perioperative complications in inguinal hernia repair - a systematic review

The current literature suggests that perioperative complications occur in 8%–10% of all inguinal hernia repairs. However, the clinical relevance of these complications is currently unknown. In our review, based on 571,445 hernia repairs reported in 39 publications, we identified the following potential risk factors: patient age, ASA score, diabetes, smoking, mode of admission (emergency vs. elective surgery), surgery in low resource settings, type of anesthesia, and (in men) bilateral and sliding hernias. The most commonly reported complications are bleeding (0.9%), wound infection (0.5%), and pulmonary and cardiovascular complications (0.2%). In 3.9% of the included publications, a reliable grading of the reported complications according to Clavien-Dindo classification was possible. Using this classification retrospectively, we could show that, in patients with complications, these are clinically relevant for about 22% of these patients (Clavien-Dindo grade ≥IIIa). About 78% of all patients suffered from complications needing only minor (meaning mostly medical) intervention (Clavien-Dindo grade <III). Especially with regard to the low incidence of complications in inguinal hernia repair, future studies should use the Clavien-Dindo classification to achieve better comparability between studies, thus enabling better correlation with potential risk factors.

Sudden death caused by acute pulmonary embolism after laparoscopic total extraperitoneal inguinal hernia repair: a case report and literature review

PURPOSE

Laparoscopic repair of inguinal hernias is an increasingly popular method of herniorrhaphy, providing advantages, including lower wound infection rates, faster recovery times and less postoperative pain compared with open procedures. The perioperative incidence of venous thromboembolism (VTE), which comprises deep vein thrombosis and pulmonary embolism, in laparoscopic inguinal hernia repair is low, but VTE is still one of the most common causes of postoperative mortality. Moreover, the VTE risk assessment and prophylaxis in inguinal hernia patients is not well defined.

METHODS

We present an unusual case of sudden death owing to acute pulmonary embolism after undergoing total extraperitoneal inguinal hernia repair. Medline and PubMed databases were searched using the keywords mentioned below, and the literature on VTE risk assessment and prophylaxis in laparoscopic inguinal hernia repair is reviewed.

RESULTS

Laparoscopic inguinal hernia repair, which is regarded as a low risk procedure for VTE, has potential risks for VTE development in the perioperative period. The risks come from both surgical procedures and intrinsic patient characteristics.

CONCLUSIONS

Clinicians should consider both the strength of individual risk factors and the cumulative weight of all risk factors prior to surgery. A full VTE risk assessment is essential with proper prophylaxis measures especially in quality-of-life procedures.

TEP or TAPP for recurrent inguinal hernia repair-register-based comparison of the outcome

Introduction

The guidelines of the international hernia societies recommend laparo-endoscopic inguinal hernia repair for recurrent hernias after open primary repair. To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. A Swiss registry study identified only minor differences between the two techniques, thus suggesting the equivalence of the two procedures.

Materials and Methods

Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n = 1,464) or TEP technique (n = 782).

Results

Univariable and multivariable analysis did not find any significant difference between TEP and TAPP with regard to the intraoperative complications, complication-related reoperations, re-recurrences, pain at rest, pain on exertion, or chronic pain requiring treatment. The only difference identified was a significantly higher postoperative seroma rate after TAPP, which was influenced by the surgical technique, previous open primary operation and EHS-classification medial and responded to conservative treatment.

Conclusion

TEP and TAPP are equivalent surgical techniques for recurrent inguinal hernia repair following previous open primary operation. The choice of technique should be tailored to the surgeon’s expertise.

Does peritoneal flap closure technique following transabdominal preperitoneal (TAPP) inguinal hernia repair make a difference in postoperative pain? A long-term quality of life comparison

BACKGROUND

Transabdominal, preperitoneal (TAPP), laparoscopic inguinal hernia repair (IHR) requires the creation of a peritoneal flap (PF) that must be closed after mesh placement. Our previous study indicated that sutured PF closure resulted in less short-term postoperative pain at 2 and 4 weeks compared to tacks and staples. Therefore, the aim of this follow-up study was to compare short-term QOL with a greater sample size and long-term QOL at 2 years by method of PF closure.

MATERIALS AND METHODS

A prospective institutional hernia-specific database was assessed for all adult TAPP IHRs from July 2012 to May 2015. QOL outcomes were compared by PF closure method at 2 and 4 weeks and 6, 12, and 24 months as measured by the Carolinas Comfort Scale. Standard statistical tests were used for the whole population and then the Bonferroni Correction was used to compare groups (p < 0.0167). Multivariate analysis controlling for age, gender, recurrent hernias, and preoperative symptomatic pain was used to compare QOL by PF closure method.

RESULTS

A total of 679 TAPP IHRs in 466 patients were analyzed; 253 were unilateral, and 213 were bilateral. PF closure was performed using tacks in 36.7 %, suture in 24.3 %, and staples in 39.0 %. There was no difference in hernia recurrence (only 1 patient at 36 months). There were no statistical differences in QOL between 2 and 4 weeks and 6- to 24-month follow-up. When resolution of symptoms from preoperative levels was examined, there was no difference in the three groups at any time point (p > 0.05). After controlling for confounding variables on multivariate analysis, there was no difference in QOL by PF closure method at any time point (p > 0.05).

CONCLUSION

Tacked, sutured, and stapled techniques for peritoneal flap closure following TAPP have no significant differences in operative outcomes, postoperative quality of life, or resolution of symptoms.

A prospective randomized comparison of testicular functions, sexual functions and quality of life following laparoscopic totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) inguinal hernia repairs

BACKGROUND

There is very scant literature on the impact of inguinal hernia mesh repair on testicular functions and sexual functions following open and laparoscopic repair. The present randomized study compares TAPP and TEP repairs in terms of testicular functions, sexual functions, quality of life and chronic groin pain.

METHODS

This study was conducted from April 2012 to October 2014. A total of 160 patients with uncomplicated groin hernia were randomized to either trans-abdominal pre-peritoneal (TAPP) repair or totally extra-peritoneal (TEP) repair. Testicular functions were assessed by measuring testicular volume, testicular hormone levels preoperatively and at 3 months postoperatively. Sexual functions were assessed using BMSFI, and quality of life was assessed using WHO-QOL BREF scale preoperatively and at 3 and 6 months postoperatively. Chronic groin pain was evaluated using the VAS scale at 3 months, 6 months and at 1 year.

RESULTS

The median duration of follow-up was 13 months (range 6-18 months). The mean preoperative pain scores (p value 0.35) as well as the chronic groin pain were similar between TEP and TAPP repairs at 3 months (p value 0.06) and 6 months (p value 0.86). The testicular resistive index and testicular volume did not show any significant change at follow-up of 3 months (p value 0.9) in the study population. No significant difference was observed in testicular resistive index and testicular volume when comparing TEP and TAPP groups at at follow-up of 3 months (p value >0.05). There was a statistically significant improvement in the sexual drive score, erectile function and overall satisfaction over the follow-up period following laparoscopic inguinal hernia repair. However, sexual function improvement was similar in patients undergoing both TEP and TAPP repairs. All the domains of quality of life in the study population showed a significant improvement at a follow-up of 3 and 6 months. Subgroup analysis of all the domains of quality of life in both TAPP and TEP groups showed a similar increment as in the study population (p value <0.001); however, the mean scores of all the domains were comparable between the two subgroups (p value >0.05), preoperatively and 3 and 6 months follow-up.

CONCLUSIONS

Laparoscopic groin hernia repair improves the testicular functions, sexual functions and quality of life, but TEP and TAPP repairs are comparable in terms of these long-term outcomes.

TEP versus TAPP: comparison of the perioperative outcome in 17,587 patients with a primary unilateral inguinal hernia

INTRODUCTION

More than 20 years since the introduction of TAPP and TEP into clinical routine, there is a lack of clarity due to conflicting comparative data. Therefore, more results from registries are needed.

PATIENTS AND METHODS

A total of 17,587 patients were enrolled prospectively between September 1, 2009, and April 15, 2013, in the Herniamed registry. Of these patients, 10,887 (61.9%) had a TAPP and 6700 (38.1%) a TEP repair. The dependent variables were intra- and postoperative complication rates, number of reoperations as well as absolute and relative frequencies. The results of unadjusted analyses were verified via multivariable analyses.

RESULTS

Multivariable analysis verified the results of unadjusted analysis, indicating that the surgical technique did not have any significant impact, also while taking account of other factors, on occurrence of intraoperative [p = 0.1648; OR = 1.214 (0.923; 1.596)] and general postoperative complications [p = 0.0738; OR = 1.315 (0.974; 1.775)]. Postoperative surgical complications [OR = 2.323 (1.882; 2.866); p < 0.0001] were noted more often after TAPP. Furthermore, the hernia defect size [p < 0.0001; I vs III: OR = 0.439 (0.313; 0.615), II vs III: OR = 0.712 (0.582; 0.872)] or scrotal [p < 0.0001; OR = 2.170 (1.501; 3.137)] hernia and age [p = 0.0002; 10-year OR = 1.135 (1.062; 1.213)] had a significant impact on the occurrence of postoperative complications. Complications were observed more commonly for larger hernia defects and a scrotal hernia. However, the difference in the postoperative complication rate between TEP and TAPP did not result in any difference in the reoperation rate (TEP 0.82% vs TAPP 0.90%; p = 0.6165).

CONCLUSION

The intraoperative and general postoperative complication rates as well as the reoperation rate for complications show no significant difference between TEP and TAPP. The higher postoperative complication rate for TAPP, which could be managed conservatively, is partly explained by larger defect sizes, more scrotal hernias and older age.

Tacks, staples, or suture: method of peritoneal closure in laparoscopic transabdominal preperitoneal inguinal hernia repair effects early quality of life

INTRODUCTION

TAPP inguinal hernia repair (IHR) entails the development of a peritoneal flap (PF) in order to reduce the hernia sac and create a preperitoneal space in which to place mesh. Many methods for closure of the PF exist including sutures, tacks, and staples. We hypothesized that patients who had PF closure with suture would have better short-term QOL outcomes.

METHODS AND PROCEDURES

A prospective institutional hernia-specific database was queried for all adult, TAPP IHRs from July 2012 to August 2013. Unilateral and bilateral patients were included and each hernia was analyzed separately. The main outcome of interest was quality of life (QOL) at two- and four-week follow-up, as measured by the Carolinas Comfort Scale.

RESULTS

There were 227 patients who underwent TAPP, with 99 bilateral and 128 unilateral IHR, for a total of 326 IHR. PF closure was performed using tacks in 45.1%, suture in 19.0%, and staples in 35.9%. Patient characteristics were statistically similar between the tack, suture, and staple group. There were 32.9% direct, 46.5% indirect, and 20.6% pantaloon hernias, which were not significantly different when compared by PF closure method. Post-operative complications and length of stay were same for the three groups. There were no hernia recurrences. Post-operative activity limitation at two weeks was significantly better in the suture group when compared to the stapled group (p = 0.005). Additionally, sutured PF closure had less early post-operative pain when compared to the tack group (p = 0.038).

CONCLUSIONS

Following TAPP IHR, suture closure of the PF significantly improves 2-week post-operative movement limitation compared to stapled and tacked PF closure. Continued randomized studies are needed to determine the best surgical hernia repair methods for ideal post-op QOL.

Laparoscopic transabdominal inguinal hernia repair in community hospital settings: a general surgeon's last 10 years experience

Numerous studies have documented the laparoscopic TransAbdominal Pre-Peritoneal (TAPP) approach as an excellent choice for inguinal hernia repair, especially with an experienced surgeon. A cohort population of patients who underwent TAPP laparoscopic surgery for inguinal hernias over the last 10 years, with follow-up, were evaluated, focusing on the feasibility, safety and benefits of this procedure in a community hospital setting.

MATERIALS AND METHODS

A total of 533 patients underwent TAPP for inguinal hernias between January 2003 and March 2013 in two community hospitals in the Northeast of Italy-"Civil Hospital" in Vittorio Veneto (TV) and "Civil Hospital" in Adria (RO).

RESULTS

The total number of hernias treated was 1,000. The overall mean operative time was 43.50 min (±13.2). All but three of the procedures were done on a day surgery basis. There were no conversions to open repair or deaths in our series. We had two cases of small bowel obstruction and eight relapses (0.8 %) in our series. The mean follow-up was 59.4 months (±5.6; range 3-120). No patients reported severe pain at 10 days, 21 patients (3.9 %) reported mild pain at 3-month follow-up. Over 90 % of the patients had a return of physical work capacity within 2 weeks, the remaining within 30 days. All patients were completely satisfied (numerical rating scale 10/10) 3 months after the operation.

CONCLUSIONS

The analysis of the short- and long-term post-operative outcomes of our experience enabled us to conclude that in an appropriate setting, TAPP is feasible, effective, safe and beneficial for patients. It should be incorporated into general surgeons' expertise and selectively used for the management of patients with hernias, as long as adequate training is obtained and appropriate preparation performed.

Use of human fibrin glue (Tisseel) versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty (TISTA): a randomized controlled trial (NCT01641718)

BACKGROUND

Inguinal hernia repair is one of the most common surgical procedures worldwide. This procedure is increasingly performed with endoscopic techniques (laparoscopy). Many surgeons prefer to cover the hernia gap with a mesh to prevent recurrence. The mesh must be fixed tightly, but without tension. During laparoscopic surgery, the mesh is generally fixed with staples or tissue glue. However, staples often cause pain at the staple sites, and they can cause scarring of the abdominal wall, which can lead to chronic pain. We designed a trial that aims to determine whether mesh fixation with glue might cause less postoperative pain than fixation with staples during a transabdominal preperitoneal patch plastic repair.

METHODS/DESIGN

The TISTA trial is a prospective, randomized, controlled, single-center trial with a two-by-two parallel design. All patients and outcome-assessors will be blinded to treatment allocations. For eligibility, patients must be male, ≥18 years old, and scheduled for laparoscopic repair of a primary inguinal hernia. One group comprises patients with a unilateral inguinal hernia that will be randomized to receive mesh fixation with either tissue glue or staples. The second group comprises patients with bilateral inguinal hernias. They will be randomized to receive mesh fixation with tissue glue either on the right or the left side and with staples on the other side. The primary endpoint will be pain under physical stress, measured at 24 h after surgery. Pain will be rated by the patient based on a numeric rating scale from 0 to 10, where 10 equals the worst pain imaginable. A total of 82 patients will be recruited (58 patients with unilateral inguinal hernias and 24 patients with bilateral hernias). This number is estimated to provide 90% power for detecting a pain reduction of one point on a numeric rating scale, with a standard deviation of one.

DISCUSSION

Patients with bilateral hernias will receive two meshes, one fixed with glue, and the other fixed with staples. This design will eliminate the inter-individual bias inherent in comparing pain measurements between two groups of patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01641718.

Laparoscopic versus open inguinal hernia repair

The laparoscopic approach to inguinal hernia surgery is safe and reliable. It has a similar recurrence rate as open tension-free mesh repair. Because the laparoscopic approach has less chronic postoperative pain and numbness, fast return to normal activities, and decreased incidence of wound infection and hematoma, it should be considered an appropriate approach for inguinal hernia surgery. These results can be achieved if a surgeon is proficient in the technique, has a clear understanding of the anatomy, and performs it on a regular basis. This article focuses on questions related to laparoscopic inguinal hernia surgery and provides answers based on published literature.