Single-port versus conventional three-port laparoscopic totally extraperitoneal inguinal hernia repair: a randomized controlled trial

TPP (totally preperitoneal) making single incision laparoscopic inguinal hernia repair more feasible: a comparison with single incision laparoscopic totally extraperitoneal hernioplasty (SIL-TEP)

BACKGROUND

Totally preperitoneal hernioplasty (TPP) is a concept which was introduced for distinguishing with totally extraperitoneal (TEP). There is few evidence reflecting the single incision laparoscopic totally preperitoneal (SIL-TPP) characteristic. The aim of study is to demonstrate the feasibility of single incision laparoscopic totally preperitoneal hernioplasty (SIL-TPP) and compare the outcomes with the single incision laparoscopic totally extraperitoneal hernioplasty (SIL-TEP) technique.

METHODS

During August 2018 and July 2022, 200 inguinal hernia patients received SIL-TPP and 56 patients received SIL-TEP in the First hospital of Ningbo university. The demographics, clinical characteristics, intraoperative and postoperative parameters were retrospectively analysed.

RESULTS

SIL-TPP and SIL-TEP hernia repair were successfully conducted in all patients. There was no conversation happened in two group. Patients' demographics were comparable when compared between the two groups adding the comparison initial 52 cases analysis (P > 0.05). The mean unilateral hernia operative time was significant shorter in the SIL-TPP group than SIL-TEP group (unilateral: 81.38 ± 25.32 vs. 95.96 ± 28.54, P: 0.001). Further study of unilateral hernia operative time revealed the mean indirect hernia operative time was significant shorter in the SIL-TPP group than SIL-TEP group (indirect: 81.38 ± 25.33 vs. 95.87 ± 28.54, P: 0.001). The unilateral hernia operation time trend of initial 52 cases of two group analysis revealed the operation time of SIL-TPP reduced faster than SIL-TEP along with treating number increasing (Figs. 2 and 3). The comparison of initial equal quantity unilateral hernia patient mean operative time revealed the SIL-TPP group was significant shorter than SIL-TEP group (85.77 ± 22.76 vs. 95.87 ± 28.54, P: 0.049). The rate of peritoneum tearing of SIL-TPP group was significant high than SIL-TEP (P = 0.005).

CONCLUSION

SIL-TPP hernia repair is a superior procedure and possess its own distinguished advantages. We recommend it rather than SIL-TEP for treating inguinal hernia, especially for indirect hernia. However, large-scale randomized controlled trials comparing SIL-TPP and SIL-TEP are needed to confirm these results.

Single-port versus multi-port totally extraperitoneal (TEP) inguinal hernia repair: A meta-analysis of randomized controlled trials

BACKGROUND

The value of single-port totally extraperitoneal inguinal hernia repair (STEP) when compared to the conventional multi-port approach (TEP) is still a matter of controversy. We conducted a meta-analysis of randomized controlled trials comparing the feasibility and safety of the above-mentioned techniques.

METHODS

A systematic literature search for randomized controlled trials (RCTs) comparing the outcome STEP and TEP in patients with inguinal hernia was conducted. Data regarding postoperative outcomes were extracted and compared by meta-analysis. The Odds Ratio and Standardized Mean Differences with 95% Confidence Intervals (CI) were calculated.

RESULTS

Six RCTs were identified, involving a total of 636 cases (STEP: n = 328, TEP: n = 308). There was a statistically significant difference noted between the 2 groups regarding return to everyday activities favoring the STEP group (SMD = -0.23; 95% CI [-0.41, -0.06]; P = .01; 4 studies; I2 = 9). For the remaining primary and secondary endpoints, intra- and postoperative morbidity, conversion rate, peritoneal tears, major intraoperative bleeding, postoperative haematoseroma, operative time, postoperative pain, chronic pain, cosmetic satisfaction, hernia recurrence and in-hospital length of stay no statistically significant difference was noted between the 2 study groups.

CONCLUSIONS

Current evidence suggests that patients who underwent STEP had similar outcomes to the traditional TEP technique with the exception of time to return to everyday activities, which was reported to be shorter in the STEP group.

Single incision laparoscopic totally preperitoneal hernioplasty (SIL-TPP): Lessons learned from 102 procedures and initial experience

BACKGROUND

The abdominal wall in groin area is conventionally considered that it was comprised by 9 layers. Single incision laparoscopy totally extraperitoneal hernioplasty (SIL-TEP) reported before were operated through the front of the posterior rectus sheath.

METHOD

102 SIL-TPP were conducted from October 2018 to October 2020 at The Affiliated Hospital of Medical School of Ningbo University using a self-made single-port device and standard laparoscopic instruments. Clinical data, demographic and intraoperative findings, and short-term postoperative outcomes were analyzed.

RESULTS

Of the 102 hernias treated, 46 were right inguinal hernias, 33 were left inguinal hernias and 23 were double-side inguinal hernias. All patients received the SIL-TPP and no conversion happened. The mean left-side and right-side hernia operative time was almost same. The left-side and right-side operative time were 75.48 ± 26.95 and 76.24 ± 26.09 minutes, respectively. The mean operative time was 75.92 ± 26.45 (range, 29-170 minutes) in unilateral inguinal hernia. Mean operative time was 104.17 ± 28.58 minutes (range, 67-180 minutes) in double-side inguinal hernia. The intraoperative complications rate was 21.57 (22/102) and all the complications were Peritoneum or sac tearing. Postoperative complications occurred in 3 cases (1 case wound seroma, 1 case urinary retension and 1 case upper respiratory infection) and were successfully treated conservatively. The mean hospital stay was 2.8646 ± 1.38 days. The 24 hours Visual analogue scale score was 2.28 ± 0.77. During follow-up to June 2022, no recurrence case occurred.

CONCLUSION

SIL-TPP is safe and feasible. SIL-TPP has its unique skills and advantages to treat inguinal hernia. Large-scale randomized controlled trials comparing SIL-TPP inguinal hernia repair with conventional single port and conventional three port laparoscopic totally extraperitoneal hernioplasty with short-term outcome and long-term recurrence rate are needed to confirm these results.

Long-term outcomes of single-incision versus multiport laparoscopic totally extra-peritoneal inguinal hernia repair: a single-institution experience of 186 consecutive cases

PURPOSE

This retrospective study was conducted to compare the long-term outcomes of single-incision totally extraperitoneal (S-TEP) inguinal hernia repair and conventional multiport totally extraperitoneal (M-TEP) inguinal hernia repair.

METHODS

The study population included 186 consecutive patients (S-TEP, n = 149; M-TEP, n = 37) who underwent elective surgery for inguinal hernia at Osaka Police Hospital between 2011 and 2013.

RESULTS

No significant between-group difference was found in patient or hernia characteristics or in perioperative outcomes, with the exception of age (S-TEP group vs. M-TEP group: median 69 [IQR 60-75] years vs. 64 [55-69] years, respectively; P = 0.019). Furthermore, no significant between-group difference was found in follow-up time (5.5 [3.0-5.8] vs. 5.4 [3.1-5.7] years, P = 0.839), recurrence rate (0.6 vs. 2.4%, P = 0.358), chronic pain (1.2 vs. 0%, P = 1.000), feeling the mesh (2.3 vs. 7.1%, P = 0.142), or movement limitation (0.6 vs. 0%, P = 1.000). All chronic symptoms were "mild but not bothersome." A metachronous contralateral inguinal hernia developed in 8.1% of patients.

CONCLUSION

The long-term outcomes of S-TEP repair were comparable to those of M-TEP, with rates of recurrence, chronic pain, feeling the mesh, and movement limitation falling within acceptable limits.

Outcomes of open versus single-incision laparoscopic totally extraperitoneal inguinal hernia repair using propensity score matching: A single institution experience

Purpose

The aim of the current study was to compare the outcomes between open and single-incision laparoscopic totally extraperitoneal (SILTEP) inguinal hernia repair.

Methods

To compare the outcomes between the open and SILTEP groups, we performed propensity score matching to adjust for significant differences in patient characteristics. The outcomes were compared between the matched groups.

Results

Record review identified 477 patients who had undergone inguinal hernia repair from November 2016 to November 2018. Seventy-one patients were excluded from the propensity score matching because of age <18, femoral hernia, conventional 3-port laparoscopic repair, incarcerated hernia, and combined operation. SILTEP in 142 and open repair in 264 patients were identified. After propensity score matching, these individuals were grouped into 82 pairs. Spinal anesthesia was administered more often in the open group than in the SILTEP group. Operation time was significantly longer in the SILTEP group than in the open group (49.6 ± 17.4 vs. 64.8 ± 28.4 min, p < 0.001). However, urinary retention rates of the open group were significantly higher than that of the SILTEP group (11.0% vs. 0%, p = 0.003). The SILTEP group showed significantly lower pain scores at postoperative 6, 12, and 24 hours, and significantly lower rates of intravenous analgesic requirements through postoperative day 1 (30.5% vs. 13.4%, p = 0.008) compared with the open group.

Conclusion

The outcomes of SILTEP repair were comparable to those of open repair. SILTEP repair may have advantages over open repair for reducing immediate postoperative pain (≤24 hours).

A prospective randomised control trial to compare the perioperative outcomes and ergonomic challenges between triangular versus midline port placement in total extra-peritoneal repair of uncomplicated unilateral inguinal hernia

BACKGROUND

Routine TEP technique requires three skin incisions for placement of three trocars in the midline. Otherwise, this can be done by three-port triangular technique or two-hand technique. This study reports a randomised trial of perioperative outcomes and ergonomics characteristics of this procedure using two different techniques of port insertion.

METHODS

N = 28 patients were randomised into two groups for triangular three-port (TTEP) versus midline three-port TEP (MTEP) hernioplasty after informed written consent in Department of Surgery, King George's Medical University UP between September 2016 and September 2017 after institutional ethical approval. Patient-related outcomes in terms of quality of life (QOL) and ergonomic evaluation of the technique were compared in double-blinded fashion.

RESULTS

Postoperative pain score at 24 h post surgery (5.1 ± 0.6; 95% CI 4.9-5.3 vs. 4.8 ± 0.4; 95% CI 4.6-4.9) differed, while hospital stay, time to return to routine work, tolerance to oral feeds and intraoperative complications occurrence (OR 2.1; 95% CI 0.2-24.3) were comparable in both groups. Time to return to office work (5.5 ± 0.5; 95% CI 5.4-5.7 vs. 4.0 ± 0.8; 95% CI 3.7-4.3) and immediate postoperative sensation of mesh and pain score were significantly higher in MTEP compared to TTEP. Ergonomic parameters including visualization of landmark score, spreading of mesh score and total surgeon satisfaction score (TTEP 8.4 ± 0.7; 95% CI 8.1-8.6 vs. MTEP 7.0 ± 0.8; 95% CI 6.7-7.3), mental effort quotient (SMEQ score: TTEP 50.6 ± 12.7; 95% CI 45.9-55.3 vs. MTEP 70.8 ± 12.6: 95% CI 66.1-75.4) and physical effort quotient (LEDQ scores in wrist, hand, arm and shoulders) were also superior in triangular technique of port placement.

CONCLUSION

Triangular three-port TEP hernioplasty is ergonomically feasible and enables a surgeon to perform surgery safely using basic principles of laparoscopy.

Patient-Reported Outcomes and Long-Term Results of a Randomized Controlled Trial Comparing Single-Port Versus Conventional Laparoscopic Inguinal Hernia Repair

BACKGROUND

Surgical techniques for inguinal hernia repair have evolved rapidly from open methods to conventional laparoscopic totally extra-peritoneal (CTEP) and recently single-port TEP (STEP). As there is currently no randomized controlled trial (RCT) reporting long-term patient-reported outcomes between CTEP and STEP, we reviewed patients who were randomized to CTEP or STEP 5 years after surgery.

METHODS

Telephone interviews were administered to patients with primary unilateral inguinal hernia recruited for the RCT comparing CTEP and STEP in 2011. The modified Body Image Questionnaire was used to measure long-term patient-reported outcomes.

RESULTS

Forty-two out of forty-nine of the STEP group and forty-one out of fifty of the CTEP group responded to phone interviews. Median follow-up time, demographic data and clinical outcomes were comparable between both groups. The Body Image Score (5-20: 5-least dissatisfied, 20-most dissatisfied; BIS score ± SD, STEP vs. CTEP, 5.33 ± 0.90 vs. 7.17 ± 1.87, p < 0.001) and Cosmetic Score (2-20: 2-least satisfied, 20-most satisfied; CS score ± SD, STEP vs. CTEP, 19.05 ± 1.31 vs. 15.87 ± 1.57, p < 0.001) were superior in the STEP group. Similarly, self-reported scar perception (1-cannot be seen, 2-can barely be seen, 3-visible; scar perception score ± SD, STEP vs. CTEP, 1.29 ± 0.51 vs. 2.55 ± 0.64, p < 0.001) and overall experience score (1-least satisfied, 10-most satisfied; overall satisfaction score ± SD, STEP vs. CTEP, 9.57 ± 0.67 vs. 8.22 ± 0.94, p < 0.001) were superior in the STEP group.

CONCLUSION

Patients who underwent STEP reported superior cosmetic and satisfaction scores and comparable surgical outcomes 5 years after surgery compared to the CTEP group. STEP should be strongly considered in patients who are concerned about long-term cosmetic outcomes and should be offered if surgical expertise is available. Trial registration NCT02302937.

A comparison of the oxidative stress response in single-incision laparoscopic versus multi-trocar laparoscopic totally extraperitoneal inguinal hernia repair

Introduction

Surgical treatment is always associated with tissue damage and the subsequent development of oxidative stress.

Aim

To compare the oxidative stress response in patients treated operatively for inguinal hernia with multi-trocar laparoscopic totally extraperitoneal technique (TEP) or single-incision laparoscopic totally extraperitoneal technique (TEP-SI).

Material and methods

A randomized group of 34 patients with one-sided inguinal hernia was enrolled in the study. Seventeen patients were treated with a standard TEP method (group 1) and the other 17 patients were treated with the TEP-SI technique (group 2). Thiobarbituric acid reactive substances (TBARS) and total antioxidant status (TAS) as the oxidative stress markers were measured before surgery (0), 1 day (1) and 4 days (2) after surgery.

Results

A decrease in TAS on the first day after surgery was observed in both groups. Sustained reduction on the fourth day after surgery was observed in group 1, whereas in group 2 an increase followed. A statistically significant difference was observed in TAS (2 : 0) ratio with a meaningful decrease in group 1. TBARS concentration was elevated 1 day after surgery in both groups. It remained at an elevated level on the fourth day after surgery in group 1, while it decreased in group 2. The duration of surgery was higher in group 2 (mean: 57.5 min) than in group 1 (mean: 50.0 min) (p = 0.0286).

Conclusions

Oxidative stress levels are lower in patients treated operatively by TEP-SI technique than by TEP. TEP-SI may be considered as a less invasive technique associated with less tissue injury.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

BACKGROUND

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

METHODS

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

RESULTS

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

CONCLUSIONS

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Abdominal peripheral nerve block as the only anesthetic technique for totally extraperitoneal endoscopic inguinal hernia repair: Two case reports

RATIONALE

Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is a rapidly evolving, minimally invasive treatment modality for inguinal hernia. Compared with open hernia repair, this method requires a smaller incision, has cosmetic advantages, and facilitates rapid recovery and early return to daily activities because of less postoperative pain. Because general anesthesia is essential for TEP hernia repair, it cannot be performed on patients who have an increased risk of developing complications when placed under general anesthesia.

PATIENT CONCERNS

We report 2 cases of single-port laparoscopic TEP (SP TEP) that were performed using only an abdominal peripheral nerve block (PNB) at our institute. General anesthesia and neuraxial block were dangerous for both patients owing to severe heart failure and severe chronic obstructive pulmonary disease (COPD).

DIAGNOSES

They were diagnosed with an inguinal hernia requiring surgery.

INTERVENTIONS

Hence, the anesthesiologist and surgeon decided to attempt a PNB to avoid complications from general anesthesia and allow faster recovery. An ipsilateral transversus abdominis plane block as well as a rectus sheath block and inguinal canal block were administered via ultrasound guidance.

OUTCOMES

The patients did not report any pain, and no rescue drug was administrated. The operation times were 65 and 62minutes in patients 1 and 2, respectively. No intraoperative complications were noted. Patient 1 was discharged the day after the surgery, whereas patient 2 was discharged on the same day as the surgery.

LESSONS

TEP hernia repair using abdominal PNB anesthesia seemed to be a safe and feasible technique without causing any additional complications. However, the use of abdominal PNB anesthesia alone for TEP hernia repair as an alternative to general anesthesia requires further investigation using a larger cohort.

Laparoendoscopic single-site surgery in inguinal hernia repair

Laparoendoscopic single-site surgery (LESS) for laparoscopic inguinal hernia repair (IHR) offers the potential for excellent cosmetic outcomes and maximization of the inherent advantages of minimally invasive surgery. LESS IHR is associated with a steep learning curve, which is attributable to both the IHR technique itself and the single-site technique. The technical obstacles in the single-site technique may be mitigated by employing certain maneuvers and strategies that minimize clashing between instruments and improve freedom of movement. The current literature consistently points out the inherent challenges in LESS IHR, with its longer operative time compared to that of conventional laparoscopic IHR. LESS IHR performed by capable operators has comparable complication rates, duration of hospital stay, and incidence of recurrence as conventional laparoscopic IHR. LESS IHR is both feasible and safe. Given its excellent cosmetic outcome, it is likely to be sought by younger patients who are concerned with scar formation. The use of robotics may bypass the technical challenges in LESS, but cost considerations in their usage will likely persist.

Randomized trial comparing self gripping semi re-absorbable mesh (PROGRIP) with polypropylene mesh in open inguinal hernioplasty: the 6 years result

OBJECTIVES

The use of absorbable polylactic acid hook self-gripping polypropylene mesh in open inguinal hernia may potentially reduce operative time and enhance patient recovery. The objective of this randomized trial is to compare the outcomes following self-gripping mesh repair to polypropylene mesh secured with sutures in open inguinal hernioplasty.

METHOD

Eligible patients aged 18-80 years old, who had primary unilateral uncomplicated inguinal hernia, were randomized into either Polypropylene (PL) group or PROGRIP (PG) group just before the placement of mesh intra-operatively by computer generated code. The primary outcome was the time from mesh placement to end of operation, whereas secondary outcomes included the total operative time, amount of analgesic used, length of post-operative stay, seroma formation, chronic discomfort, chronic pain score and recurrence. The study has been registered in http://www.clinicaltrial.gov carrying an ID of NCT00960011. Patients were followed-up in outpatient clinic for up to 6 years after operation.

RESULTS

From March 2009 to April 2016, 45 patients were included. The mean age of PG group (n = 22) was 62.0 ± 15.7 years old while that of the PL group was 62.6 ± 4.9 years old (n = 23). There was no significant difference regarding the smoking habit, drinking habit, comorbidities, previous hernia operation and Nyhus type of hernia between the two groups. The size of defects, the time of groin dissection and the size of incision were similar. In the PG group, there was significant reduction in the time for mesh placement (11.8 ± 3.1 vs. 21.0 ± 6.2 min, p < 0.001) and total operative time (39.2 ± 9.8 vs. 47.7 ± 8.0 min, p = 0.003). There was one recurrence in PL group and nil in PG group. Although there was a significant difference in paresthesia between 2 groups after operation, the difference disappears with time and comparable from post-operative 1 year onwards. There was no difference in chronic pain, chronic discomfort, affect daily activities, palpable mesh demonstrated throughout the whole study period till 6 years after operation.

CONCLUSIONS

The use of polylactic acid self-gripping mesh in open inguinal hernia repair effectively reduces the operating time with comparable long-term surgical outcome with traditional polypropylene mesh.