Transinguinal preperitoneal repair with the Polysoft patch: prospective evaluation of recurrence and chronic pain

Transinguinal preperitoneal (TIPP) versus minimally invasive inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

The transinguinal preperitoneal (TIPP) technique is an open approach to groin hernia repair with posteriorly positioned mesh supposed to reduce recurrence rates. However, transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques have similar mesh positioning with the advantages of minimally invasive surgery (MIS). Hence, we performed a systematic review and meta-analysis comparing TIPP and MIS for groin hernia repair.

SOURCE

Cochrane, Embase, Scopus, Scielo, and PubMed were systematically searched for studies comparing TIPP and MIS techniques for groin hernia repair. Outcomes assessed were recurrence, chronic pain, surgical site infection (SSI), seroma, and hematoma. We performed a subgroup analysis of TAPP and TEP techniques separately. Statistical analysis was performed with R Studio.

PRINCIPAL FINDINGS

81 studies were screened and 19 were thoroughly reviewed. Six studies were included, of which two compared TIPP with TEP technique, two compared TIPP with TAPP, and two compared TIPP with both TEP and TAPP techniques. We found lower recurrence rates for the TEP technique compared to TIPP (0.38% versus 1.19%; RR 2.68; 95% CI 1.01 to 7.11; P = 0.04). Also, we found lower seroma rates for TIPP group on the overall analysis (RR 0.21; P = 0.002). We did not find statistically significant differences regarding overall recurrence (RR 1.6; P = 0.19), chronic pain (RR 1.53; P = 0.2), SSI (RR 2.51; P = 0.47), and hematoma (RR 1.29; P = 0.76) between MIS and TIPP. No statistically significant differences were found in the subgroup analysis of TAPP technique for all the outcomes.

CONCLUSION

Our systematic review and meta-analysis found no differences between TIPP and MIS approaches in the overall analysis of recurrence, SSI, and chronic pain rates. Further research is needed to analyze individual techniques and draw a more precise conclusion on this subject.

PROSPERO REGISTRATION

ID CRD42024530107, April 8, 2024.

Transinguinal preperitoneal (TIPP) versus Lichtenstein for inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

We aimed to perform a systematic review and meta-analysis comparing postoperative outcomes in inguinal hernia repair with TIPP versus Lichtenstein technique.

METHODS

Cochrane Central, Scopus, and PubMed were systematically searched for studies comparing TIPP and Lichtenstein´s technique for inguinal hernia repair. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, the Visual Analogue Pain Score, chronic pain, paresthesia rates, and recurrence. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics and random-risk effect was used if I2 > 25%.

RESULTS

790 studies were screened and 44 were thoroughly reviewed. A total of nine studies, comprising 8428 patients were included, of whom 4185 (49.7%) received TIPP and 4243 (50.3%) received Lichtenstein. We found that TIPP presented less chronic pain (OR 0.43; 95% CI 0.20-0.93 P = 0.03; I2 = 84%) and paresthesia rates (OR 0.27; 95% CI 0.07-0.99; P = 0.05; I2 = 63%) than Lichtenstein group. In addition, TIPP was associated with a lower VAS pain score at 14 postoperative day (MD - 0.93; 95% CI - 1.48 to - 0.39; P = 0.0007; I2 = 99%). The data showed a lower operative time with the TIPP technique (MD - 7.18; 95% CI - 12.50, - 1.87; P = 0.008; I2 = 94%). We found no statistical difference between groups regarding the other outcomes analyzed.

CONCLUSION

TIPP may be a valuable technique for inguinal hernias. It was associated with lower chronic pain, and paresthesia when compared to Lichtenstein technique. Further long-term randomized studies are necessary to confirm our findings. Study registration A review protocol for this meta-analysis was registered at PROSPERO (CRD42023434909).

Single-blind randomized clinical trial of transinguinal preperitoneal repair using self-expanding mesh patch vs. Lichtenstein repair for adult male patients with primary unilateral inguinal hernia

PURPOSE

The aim of the study was to compare proportions of chronic postoperative inguinal pain (CPIP) and other surgical outcomes between transinguinal preperitoneal repair with modified Kugel patch (MK) and Lichtenstein repair (LR).

METHODS

Two-hundred adult male patients with primary unilateral inguinal hernia were randomized into MK or LR groups. The primary endpoint was CPIP, pain at 6 months after surgery. Secondary outcomes included recurrence rate, incidence of postoperative complications, time until return to activities, inguinal pain and sensory disturbances assessed at 1 week, 1 month, 3, 6, and 12 months after the operation using an 11-point numerical rating scale (NRS). The study was an intention-to-treat analysis.

RESULTS

In comparison of MK (n = 100) and LR (n = 100) with similar backgrounds, proportions of CPIP were similar (7.2 vs. 11.1%, p = 0.3452). Favorable outcomes for MK were duration of operation (32 vs. 40 min, p < 0.0001), NRS of foreign body sensation at 1 year (0 [0-1] vs. 0 [0-2], p = 0.0067), and NRS of numbness at 1 month (0 [0-1] vs. 0 [0-3], p = 0.0078) after the operation.

CONCLUSIONS

In regard to CPIP, the short-term results of MK and LR were similar.

Transinguinal preperitoneal repair of giant inguinoscrotal hernias using Kugel mesh

INTRODUCTION

Giant inguinoscrotal hernias are rarely encountered in clinical settings, and their repair is technically challenging. The aim of this study is to evaluate the efficacy of transinguinal preperitoneal repair (TIPP) of giant inguinoscrotal hernias using Kugel mesh.

METHODS

A retrospective analysis was conducted on 9 patients with 11 giant inguinoscrotal hernias who underwent TIPP repair using Kugel mesh between December 2008 and January 2019. Demographics and perioperative and postoperative data were collected, and the operative experience was summarized.

RESULTS

The patients underwent a successful repair procedure with simultaneous omentectomy but without resection of the other abdominal organs. The median operation time was 120min, the median intraoperative blood loss was 75mL and the median defect area was 72 cm². The median duration for diet restoration was 4 days, and the median postoperative hospital stay was 6 days. The drainage tube placed in the preperitoneal space was removed after a median duration of 5 days, and the drainage tube placed in the distal hernia sac was removed after a median duration of 6 days. Three patients suffered from a postoperative increase in intra-abdominal pressure, while one patient deteriorated into abdominal compartment syndrome accompanied by respiratory dysfunction. No haematomas, seromas, incisional or mesh infections, recurrence or chronic pain occurred during the follow-up period.

CONCLUSIONS

TIPP repair using Kugel mesh is a feasible and effective method for giant inguinoscrotal hernias.

Long-term results from a randomized comparison of open transinguinal preperitoneal hernia repair and the Lichtenstein method (TULIP trial)

Background

The short‐term results of the TULIP trial comparing transinguinal preperitoneal (TIPP) inguinal hernia repair with the Lichtenstein method have been reported with follow‐up of 1 year. After TIPP repair, fewer patients had chronic postoperative inguinal pain (CPIP); they had better health status and lower costs. The present study reports the long‐term outcomes of this trial.

Methods

All surviving patients initially randomized in the TULIP trial were contacted. Patients were interviewed by telephone and sent a questionnaire. Those reporting any complaints were invited for outpatient review. Chronic pain, hernia recurrence and reoperation were documented, along with any sensory change or disturbance of sexual activity.

Results

Of 302 patients initially randomized, 251 (83·1 per cent) were included in the analysis (119 TIPP, 132 Lichtenstein), with a median follow‐up of 85 (range 74–117) months. Of 25 patients with chronic postoperative inguinal pain after 1 year, only one, who underwent Lichtenstein repair, still had groin pain at long‐term follow‐up. The overall hernia recurrence rate was 2·8 per cent (7 patients), with no difference between the groups.

Conclusion

Both TIPP and Lichtenstein hernia repairs are durable. Patients with chronic postoperative inguinal pain after 1 year can be reassured that the groin pain tends to fade over time.

Rives Technique for the Primary Larger Inguinal Hernia Repair: A Prospective Study of 1000 Repairs

Objective

We report a prospective study of repairs using the Rives technique of the more difficult primary inguinal hernias, focusing on the immediate post-operative period, clinical recurrence, testicular atrophy, and chronic pain. A mesh placed in the preperitoneal space can reduce recurrences and chronic pain.

Methods

For the larger primary inguinal hernias (Types 3, 4, 6, and some 7), we favour preperitoneal placement of a mesh, covering the myopectineal orifice by means of a transinguinal (Rives technique) approach. The Rives technique was performed on 943 patients (1000 repairs), preferably under local anaesthesia plus sedation in ambulatory surgery.

Results

The mean operative time was 31.8 min. Pain assessment after 24 h with an Andersen scale and a categorical scale gave two patients with intense pain on the Andersen scale, and four patients who thought their state was bad. Surgical wound complications were below 1%, and urinary retention was 1.2% mostly associated with spinal anaesthesia and, in one case, bladder perforation. There was spermatic cord and testicular oedema with some degree of orchitis in 17 patients. The clinical follow-up of 849 repairs (86.4%), mean (range) 30.0 (12–192) months, gave five recurrences (0.6%), three cases (0.4%) of testicular atrophy, and 37 (4.3%) of post-operative chronic pain (8 patients with visual analogue scale of 3–10).

Conclusions

The Rives technique requires a sound knowledge of inguinal preperitoneal space anatomy, but it is an excellent technique for the larger and difficult primary inguinal hernias, giving a low rate of recurrences and chronic pain.

Open preperitoneal groin hernia repair with mesh: A qualitative systematic review

BACKGROUND

For the repair of inguinal hernias, several surgical methods have been presented where the purpose is to place a mesh in the preperitoneal plane through an open access. The aim of this systematic review was to describe preperitoneal repairs with emphasis on the technique.

DATA SOURCES

A systematic review was conducted and reported according to the PRISMA statement. PubMed, Cochrane library and Embase were searched systematically. Studies were included if they provided clinical data with more than 30 days follow up following repair of an inguinal hernia with an open preperitoneal mesh technique.

CONCLUSIONS

A total of 67 articles were included, describing nine different methods: Kugel, TREPP, TIPP, Onstep, Horton/Florence, Nyhus, Ugahary, Read, and Stoppa. In general, results regarding pain, recurrences and complications seem promising. It was not possible to conduct a meta-analysis. Open preperitoneal techniques with placement of a mesh through an open approach seem promising compared with the standard anterior techniques. This systematic review provides an overview of these techniques together with a description of surgical methods and clinical outcomes.

Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair Using Memory-Ring Mesh: A Pilot Study

Purpose. To evaluate the feasibility, safety, and effectiveness of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair using a memory-ring patch (Polysoft™ mesh). Patients and Methods. Between April 2010 and March 2013, a total of 76 inguinal hernias underwent TAPP repair using Polysoft mesh in 67 adults under general anesthesia. Three different senior resident surgeons performed TAPP repair under the instruction of a specialist surgeon. Nine patients had bilateral hernias. The 76 hernias included 37 indirect inguinal hernias, 29 direct hernias, 1 femoral hernia, 1 pantaloon hernia (combined direct/indirect inguinal hernia), and 8 recurrent hernias after open anterior hernia repair. The immediate postoperative outcomes as well as the short-term outcomes (mainly recurrence and incidence of chronic pain) were studied. Results. There was no conversion from TAPP repair to anterior open repair. The mean operation time was 109 minutes (range, 40–132) for unilateral hernia repair. Scrotal seroma was diagnosed at the operation site in 5 patients. No patient had operation-related orchitis, testicle edema, trocar site infection, or chronic pain during follow-up. Conclusions. The use of Polysoft mesh for TAPP inguinal hernia repair does not seem to adversely affect the quality of repair. The use of this mesh is therefore feasible and safe and may reduce postoperative pain.

The transinguinal preperitoneal technique (TIPP) in inguinal hernia repair does not cause less chronic pain in relation to the ProGrip technique: a prospective double-blind randomized clinical trial comparing the TIPP technique, using the PolySoft mesh, with the ProGrip self-fixing semi-resorbable mesh

BACKGROUND

Position of the mesh and the method of fixation are important in the occurrence of chronic pain in inguinal herniorrhaphy. An RCT was conducted to evaluate chronic pain after transinguinal preperitoneal (TIPP) repair compared with a Lichtenstein-like repair with a semi-resorbable self-fixing mesh (ProGrip).

METHODS

Patients with a primary unilateral inguinal hernia were randomized either to the TIPP (PolySoft mesh) or to repair with a ProGrip mesh. Primary objective was the occurrence of chronic pain after surgery. Secondary objectives were, i.e., recurrences, complications, and quality of life. Follow-up occurred after 2 weeks, 3 months, and 1 year. Patients and physicians were blinded.

RESULTS

Two hundred and fifty-eight patients were randomized to TIPP or ProGrip mesh repair. Two hundred and thirty-eight were included in the analysis: 122 in the TIPP group and 116 in the ProGrip group. Baseline characteristics were compatible. After 2 weeks and 3 months, there was significantly more moderate and severe pain in the ProGrip group on different pain scores. Median pain scores were very low in both groups after 3 months and 1 year (0-0.5 on a scale of 0-10). There was no difference in pain scores between both groups after 1 year. Recurrence rates were low; three patients in each group (2.6 % ProGrip and 2.5 % TIPP).

CONCLUSION

There was no significant difference in chronic pain between the inguinal repairs with the use of a ProGrip mesh compared with a TIPP repair at 1 year after surgery. In both groups, the occurrence of chronic pain was low.

Modified Kugel herniorrhaphy using standardized dissection technique of the preperitoneal space: long-term operative outcome in consecutive 340 patients with inguinal hernia

PURPOSE

The aim of this study was to evaluate the outcome, with a special reference to recurrence and postoperative chronic pain, of the modified Kugel herniorrhaphy (MKH) using standardized dissection of the preperitoneal space.

PATIENTS AND METHODS

Operative results were examined based on medical records and questionnaire surveys in 340 consecutive cases of MKH performed at a single institution. The operation was performed with an original 3-stage dissection of the preperitoneal space only via the internal inguinal ring.

RESULTS

The mean follow-up period was 50.5 ± 24.3 months. The mean operating time was 42.2 ± 13.1 min, and by Nyhus classification, significant difference was observed between types IIIA and IIIB (39.5 ± 10.8 vs. 45.6 ± 15.6 min, P = 0.0279). Eight surgeons performed 10 or more operations, and no significant difference was found in their operating time. Thirty-one patients used additional analgesics postoperatively (9.1 %) and the length of postoperative stay was 1.2 ± 0.7 days. Seven patients (2.1 %) developed complications related to the hernia operation, but none of them required re-operation. The period required to return to normal daily activities was 3 ± 3.2 days. Questionnaire forms were returned from 77.7 % of all the patients, in which 12 patients reported chronic pain (4.7 %). Visual analog scale for patients with chronic pain scored 3.8 ± 2.4, with no patient indicating restrictions on daily life. Recurrence was observed in only one case (0.3 %).

CONCLUSION

MKH using standardized dissection of the preperitoneal space is a highly reproducible procedure with acceptable rate of postoperative chronic pain and recurrence.

Chronic pain and quality of life (QoL) after transinguinal preperitoneal (TIPP) inguinal hernia repair using a totally extraperitoneal, parietalized, Polysoft ® memory ring patch : a series of 622 hernia repairs in 525 patients

INTRODUCTION

Little is known about both incidence of chronic pain and quality of life (QoL) after the transinguinal preperitoneal (TIPP) technique using a totally extraperitoneal, parietalized, memory ring patch.

MATERIALS AND METHODS

Among 622 (428 unilateral and 194 bilateral) hernia repairs (HR) in 525 patients, 92 % had a postoperative clinical control. Thereafter, two sets of postal self-assessed questionnaires were sent.

RESULTS

A total of 531 HR were studied with a mean follow-up of 17 ± 8 months. Only one recurrence was detected. In 151 (28.4 %) HR the patients alleged various symptoms, but in only 10 (1.9 %) HR they considered their discomfort more bothersome than the hernia they had before, and in just 2 (0.4 %) HR they judged their result as bad (one patch removal for sepsis and one for hematoma). Only mild pain (including no painful discomfort such as a foreign body sensation) or moderate pain was frequent. Pain was self-graded as severe in four cases. None of them reported any regular consumption of antalgics. None of them judged their result as bad. Dysesthesia (numbness 19, paresthesia 20) mentioned in 39 HR (7 %), associated with pain in 16 HR, was said to be more bothersome than the hernia treated in just 3 HR (0.6 %). The results of the entire series were self-assessed as good or excellent in 97 % of the HR.

CONCLUSION

In our TIPP series, both the incidence of recurrences (0.2 %) and that of severe chronic pain (≤0.7 %) were very low, as well as patients' QoL was excellent. In our experience, the postoperative course was as painless as that of laparoscopic TEP we had been performing previously, but TIPP appeared more suited to day-case surgery.

Transinguinal preperitoneal groin hernia repair using a preperitoneal mesh preformed with a permanent memory ring: a good alternative to Lichtenstein's technique

PURPOSE

The transinguinal preperitoneal (TIPP) technique uses a preperitoneal mesh preformed with a permanent memory ring, which greatly facilitates application of Rives' technique. The purpose of this retrospective study was to evaluate our primary results by systematic clinical and ultrasound evaluations more than 1 year after surgery.

METHODS

This unicentric study included all consecutive adult patients treated with surgery for a groin hernia by the same surgeon using the same technique between December 2006 and December 2008. Any patient who participated in this study had both a systematic clinical and ultrasound control between 6 months and 3 years after surgery.

RESULTS

In this study, we performed 145 hernia repairs. There was no infection of the mesh and no clinical recurrence; additionally there was an ultrasound recurrence (n = 3) in 2% of asymptomatic patients and chronic pain in 4.8% of patients who did not require the consumption of systematic painkillers and are not limited in their activities.

CONCLUSIONS

It is feasible to correct a groin hernia using a preperitoneal preformed mesh with a permanent memory ring. Our study confirms the positive results of Pélissier and colleagues (Pélissier and Ngo, Ann Chir 131:590-594, 2006; Pélissier et al. J Chir 144(4):5S35-5S40, 2007; Pélissier et al. Hernia 11:229-234, 2007; Pélissier et al. Hernia 12:51-56, 2007) and Berrevoet et al. (Hernia 13:243-249, 2009; Langenbeck's Arch Surg 395:557-562, 2010) and is the first study to use a systematic clinical and ultrasound control more than 1 year after surgery. This technique has a low rate of complications, including ultrasound recurrence in 2% of patients without any clinical recurrence and chronic pain in 4.8% of patients who did not require the consumption of systematic painkillers and are not limited in their activities. This technique consisted of the placement of a patch in the preperitoneal space, which combines the benefits of the anterior approach (i.e., easy technique, short learning curve, low cost) and the preperitoneal placement of the mesh (less recurrence, less pain). This procedure is a good alternative to Lichtenstein's technique.

The preperitoneal memory-ring patch for inguinal hernia: a prospective multicentric feasibility study

PURPOSE

To evaluate the feasibility, the reproducibility, the safety and the efficacy of a recently introduced preperitoneal memory-ring patch (Polysoft, Davol Inc., C.R. Bard Inc., Crawley, UK) by a prospective multicentric observational study.

METHODS

We performed 235 unilateral groin hernia repairs in 200 consecutive patients during a 12-month period. Patients were operated by three different surgeons in two different centres. Pre- and intraoperative data, as well as postoperative complications, were prospectively recorded.

RESULTS

Two hundred patients, with a mean age of 55.4 years, were operated for primary or recurrent unilateral groin hernias. The mean operation time for unilateral hernia repair was 22 min (range 14-37 min). Seventy-one patients (35.5%) were operated in an ambulatory setting. Considering pain scores, we observed a preoperative visual analogue scale (VAS) score of 1.4 (range 0-3.7). After 24 h, 3 weeks and 6 months, VAS was 4.2 (0.5-6.9), 1.7 (0-2.0) and 0.1 (0-1.5), respectively. The follow-up was more than 18 months in all patients (range 19-31 months). In total, three patients were diagnosed with a recurrence and were reoperated by an anterior Lichtenstein repair with large-pore mesh.

CONCLUSION

This transinguinal minimally invasive preperitoneal mesh repair is reproducible, easy to perform and safe with acceptable mid-term results. These elements, together with a minimal superficial dissection in the inguinal canal, preperitoneal mesh placement and the absence of fixation, are possible elements to reduce acute and chronic postoperative pain compared to other open and also laparoscopic techniques that have to be proven in larger (randomised) trials.