A national trainee-led audit of inguinal hernia repair in Scotland

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.

Utilization of laparoscopic and open inguinal hernia repair at a large hernia center in China: a single-center observational study

BACKGROUND

The utilization of laparoscopic and open inguinal hernia repair in China remains unclear. We aim to investigate the rates of laparoscopic and open inguinal hernia repairs and its associated factors at a large hernia center.

METHODS

Data were obtained from the front sheet of medical records of Beijing Chaoyang hospital. Adult inguinal hernia inpatients who underwent hernia repairs between 2013 and 2020 were included. We calculated the overall rates of laparoscopic and open inguinal hernia repairs and compared the rate of laparoscopic repairs between different sex, age groups, types, and sides of inguinal hernias. Multivariable logistic regression was used to examine factors associated with the rate of laparoscopic repairs.

RESULTS

14,481 inpatients with inguinal hernia were included. 91.78% were male, 75.43% were more than 50 years, 75.20% were unilateral inguinal hernia, and 64.57% were indirect inguinal hernia. Overall, 49.47% underwent laparoscopic repairs and 50.53% underwent open repairs. Women had lower rate of laparoscopic repair than men, especially in those with unilateral hernias. Bilateral and direct inguinal hernia had higher rates of laparoscopic repair than unilateral and indirect inguinal hernia. Multivariable logistic regression showed that inpatients who were women, > 70 years, pantaloon inguinal hernia, with obstruction, and more comorbidities were less likely to have laparoscopic repairs.

CONCLUSION

Around 50% of inguinal hernia patients at a large hernia center underwent laparoscopic repairs, which was more commonly performed in male, young, bilateral inguinal hernia, and inpatients without comorbidities. More efforts were needed to increase the safe and effective laparoscopic utilization among female patients with inguinal hernias.

Adherence to international guidelines for Groin Hernia Management: a retrospective cross-sectional study in a tertiary government training hospital

PURPOSE

This study aims to determine overall compliance of the Department of Surgery in a tertiary government training hospital to the latest International Guidelines for Groin Hernia Management from July to December 2018.

METHODS

Medical records of operations involving inguinal hernia in adults done from July to December 2018 (N = 150) were reviewed and compliance rates were determined based on selected ten parameters.

RESULTS

Overall, the Department of Surgery was poorly compliant to the guidelines. All cases were only partially compliant. The highest over-all compliance was noted on the use of clinical examination alone in diagnosing primary inguinal hernias (N = 147, 100%, recurrent hernias excluded), use of appropriate technique (N = 147, 98%), and use of preoperative antibiotics (N = 144, 96%). Poor compliance was noted on round ligament preservation in females (0%), use of intraoperative local anesthesia (N = 5, 3%), and the use of European Hernia Society Classification in the final diagnosis (N = 42, 28%).

CONCLUSION

Strict education, implementation, and regular monitoring of these guidelines among both the resident and consultant staff are needed to ensure better compliance to the guidelines.

National multicentre audit of pregnancy status in general surgery admissions in Scotland

BACKGROUND

Documentation of pregnancy status (PS) is an integral component of the assessment of women of reproductive age when admitted to hospital. Our aim was to determine how accurately PS was documented in a multicentre audit of female admissions to general surgery.

METHODS

A prospective multicentre audit of elective and emergency admissions was performed in 18 Scottish centres between 08:00 on 11 May 2015 and 07:59 on 25 May 2015. The lower age limit was the minimum age for admission to the adult surgical ward and the upper age limit was 55 years.

RESULTS

There were 2743 admissions, with 612 (22.3%) women of reproductive age. After 82 exclusions, the final total was 530: 169 (31.9%) elective and 361 (68.1%) emergency. Documentation of PS was achieved in 274 (51.7%) cases: 52 (30.8%) elective and 222 (61.5%) emergency. In 318 (88.1%) of the emergency admissions, the patient had abdominal pain. Of these, 211 (65.1%) had a documented PS. The possibility of pregnancy was established in 237 (44.7%) cases.

DISCUSSION

Establishing the possibility of pregnancy before surgery is poor, particularly in the elective setting. Objective documentation of PS in the emergency setting in those with abdominal pain is also poor. Our study highlights an important safety issue in the management of female patients. We advocate electronic storage of pregnancy test results and new guidelines to cover both elective and emergency surgery. PS should form part of the pre-theatre safety brief and checklist.