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Zwols TLR, van der Bilt ARM, Veeger NJGM, Möllers MJW, Hess DA, Brandsma HT, Jutte E, Veldman PHJM, Eker HH, Koning GG, Pierie JPEN. Learning and implementation of TransREctus sheath PrePeritoneal procedure for inguinal hernia repair. Hernia 2024:10.1007/s10029-024-03031-x. [PMID: 38760626 DOI: 10.1007/s10029-024-03031-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/17/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE The TransREctus sheath PrePeritoneal procedure (TREPP) was introduced as an alternative open and preperitoneal technique for inguinal hernia mesh repair, demonstrating safety and efficacy in retro- and prospective studies. However, little is known about the technique's inherent learning curve. In this study, we aimed to determine TREPP learning curve effects after its implementation in high-volume surgical practice. METHODS All primary, unilateral TREPP procedures performed in the first three years after implementation (between January 2016 and December 2018) were included out of a large preconstructed regional inguinal hernia database. Data were analyzed on outcome (i.e., surgical complications, hernia recurrences, postoperative pain). Learning curve effects were analyzed by assessing outcome in relation to surgeon experience. RESULTS In total, 422 primary, unilateral TREPP procedures were performed in 419 patients. In three patients a unilateral TREPP procedure was performed on both sides separated in time. A total of 99 surgical complications were registered in 83 procedures (19.6% of all procedures), most commonly inguinal postoperative pain (8%) and bleeding complications (7%). Hernia recurrences were observed in 17 patients (4%). No statistically significant differences on outcome were found between different surgeon experience (< 40 procedures, 40-80 procedures, > 80 procedures). CONCLUSION Implementation of TREPP seems not to be associated with a notable increase of adverse events. We were not able to detect a clear learning curve limit, potentially suggesting a relatively short learning curve among already experienced hernia surgeons compared to other guideline techniques.
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Affiliation(s)
- T L R Zwols
- Postgraduate School of Medicine, University Medical Centre Groningen, Groningen, The Netherlands.
| | | | - N J G M Veeger
- MCL Academy, Medical Center Leeuwarden, Leeuwarden, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M J W Möllers
- Department of Surgery, Nij Smellinghe Hospital, Drachten, The Netherlands
| | - D A Hess
- Department of Surgery, Antonius Hospital, Sneek, The Netherlands
| | - H T Brandsma
- Department of Surgery, Antonius Hospital, Sneek, The Netherlands
| | - E Jutte
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - P H J M Veldman
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - H H Eker
- Department of Surgery, University Hospital, Ghent, Belgium
| | - G G Koning
- Department of Surgery, Euregio Hospital, Nordhorn, Germany
| | - J P E N Pierie
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
- Postgraduate School of Medicine, University Medical Centre Groningen, Groningen, The Netherlands
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Rodrigues-Gonçalves V, Verdaguer-Tremolosa M, Martínez-López P, Fernandes N, Bel R, López-Cano M. Open vs. robot-assisted preperitoneal inguinal hernia repair. Are they truly clinically different? Hernia 2024:10.1007/s10029-024-03050-8. [PMID: 38704470 DOI: 10.1007/s10029-024-03050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/14/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Inguinal hernia repair lacks a standard repair technique, with laparo-endoscopic and open preperitoneal methods showing similar outcomes. Despite higher costs, the popularity of robotic surgery is on the rise, driven by technological advantages. Controversies persist in comparing open repair techniques with the robotic approach, given contradictory results. The objective of this study was to compare postoperative outcomes, including complications, chronic pain, and recurrence, between open and robotic-assisted preperitoneal inguinal hernia repair. METHODS This single-center retrospective study encompassed patients undergoing elective inguinal hernia repair in a specialized unit, employing both open preperitoneal and robotic-assisted laparoscopic approaches from September 2018 to May 2023. Comparative analysis of short- and long-term outcomes between these techniques was conducted. Additionally, multivariate logistic regression was employed to explore predictors of postoperative complications. RESULTS A total of 308 patients met the inclusion criteria. 198 (64%) patients underwent surgery using an open preperitoneal approach and 110 (36%) using robot-assisted laparoscopy. Patients in the robot-assisted group were younger (P = 0.006) and had fewer comorbidities (P < 0.001). There were no differences between the groups in terms of postoperative complications (P = 0.133), chronic pain (P = 0.463) or recurrence (P = 0.192). Multivariate analysis identified ASA ≥ III (OR, 1.763; 95%CI, 1.068-3.994; P = 0.027) and inguinoscrotal hernias (OR, 2.371, 95%CI, 1.407-3.944; P = 0.001) as risk factors of postoperative complications. CONCLUSIONS Both open preperitoneal and robotic-assisted laparoscopic approaches show similar outcomes for complications, chronic pain, and recurrence when performed by experienced surgeons. The open preperitoneal approach, with its quicker operative time, may be advantageous for high-comorbidity cases. Treatment choice should consider patient factors, surgeon experience, and healthcare resources.
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Affiliation(s)
- V Rodrigues-Gonçalves
- General Surgery Department, Abdominal Wall Surgery Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Paseo Vall d`Hebron 119-129, 08035, Barcelona, Spain.
| | - M Verdaguer-Tremolosa
- General Surgery Department, Abdominal Wall Surgery Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Paseo Vall d`Hebron 119-129, 08035, Barcelona, Spain
| | - P Martínez-López
- General Surgery Department, Abdominal Wall Surgery Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Paseo Vall d`Hebron 119-129, 08035, Barcelona, Spain
| | - N Fernandes
- General Surgery Department, Abdominal Wall Surgery Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Paseo Vall d`Hebron 119-129, 08035, Barcelona, Spain
| | - R Bel
- General Surgery Department, Abdominal Wall Surgery Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Paseo Vall d`Hebron 119-129, 08035, Barcelona, Spain
| | - M López-Cano
- General Surgery Department, Abdominal Wall Surgery Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Paseo Vall d`Hebron 119-129, 08035, Barcelona, Spain
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Bharani T, Agarwal D, Fullington N, Ott L, Olson M, McClain D, Lima L, Poulose B, Warren J, Reinhorn M. Open preperitoneal inguinal hernia repair has superior 1-year patient-reported outcomes compared to Shouldice non-mesh repair. Hernia 2024; 28:475-484. [PMID: 38142262 DOI: 10.1007/s10029-023-02936-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/17/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION The Shouldice method for inguinal hernia repair remains the gold standard for prosthesis-free repairs. Nonetheless, international guidelines have favored posterior mesh reinforcement as the standard of care for inguinal hernia repair due to lower risk of recurrence and chronic pain, avoidance of general anesthesia, and favorable biomechanical properties. Recent publications have shown the benefits of an open approach to posterior repairs. Herein, we use the Abdominal Core Health Quality Collaborative (ACHQC) registry to compare patient-reported outcomes after a Shouldice no-mesh repair versus open preperitoneal (OPP) mesh repair. METHODS We performed a propensity score matched analysis to compare patient-reported quality of life (QoL) and peri/postoperative outcomes after a Shouldice repair versus OPP. Data from 2012 to 2022 were obtained from the ACHQC, and 1:1 optimal matching was performed. EuraHS scores were used to estimate QoL, and further analysis on the EuraHS domains of pain, aesthetics, and activity restriction were performed between the two cohorts. RESULTS Matching resulted in 257 participants in each, Shouldice and OPP cohorts. OPP was associated with a better QoL score compared to Shouldice at 30 days after surgery (Median (IQR) 7.75 (2.0-17.0) vs 13.0 (4.0-26.1); OR 0.559 [0.37, 0.84]; p = 0.003). This difference persisted at 6 months and 1 year postoperatively (OR 0.447 [0.26, 0.75] and 0.492 [0.26, 0.93], respectively). We did not observe any significant differences in hernia recurrence risk at 1-year, or rates of 30-day SSOs/SSIs, postoperative bleeding, peripheral nerve injury, DVTs, or UTIs. CONCLUSION Our data suggest that OPP is associated with significantly better patient-reported QoL, in the first month after surgery and up to 1 year postoperatively, especially with respect to lesser pain, when compared to the Shouldice repair. In specialized inguinal hernia practices, open posterior mesh repairs may lead to better outcomes than non-mesh repairs. We encourage more training in both repairs to facilitate larger prospective studies and evaluation of the generalizability of these results to all surgeons performing IHR.
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Affiliation(s)
- Tina Bharani
- Department of Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Divyansh Agarwal
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St., GRB 425, Boston, MA, 02114, USA.
| | - Nora Fullington
- Boston Hernia, 20 Walnut Street, Suite 100, Wellesley, MA, 02481, USA
- Mass General Brigham-Newton Wellesley Hospital, Newton, MA, USA
| | - Lauren Ott
- Boston Hernia, 20 Walnut Street, Suite 100, Wellesley, MA, 02481, USA
- Mass General Brigham-Newton Wellesley Hospital, Newton, MA, USA
| | - Molly Olson
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Daelyn McClain
- Boston Hernia, 20 Walnut Street, Suite 100, Wellesley, MA, 02481, USA
| | - Lulu Lima
- Boston Hernia, 20 Walnut Street, Suite 100, Wellesley, MA, 02481, USA
| | - Benjamin Poulose
- Center for Abdominal Core Health, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jeremy Warren
- Department of Surgery, Division of Minimal Access, and Bariatric Surgery, Prisma Health Upstate, 701 Grove Rd, ST 3, Greenville, SC, 29605, USA
| | - Michael Reinhorn
- Boston Hernia, 20 Walnut Street, Suite 100, Wellesley, MA, 02481, USA.
- Mass General Brigham-Newton Wellesley Hospital, Newton, MA, USA.
- Tufts University School of Medicine, Boston, MA, USA.
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Agarwal D, Bharani T, Fullington N, Ott L, Olson M, Poulose B, Warren J, Reinhorn M. Improved patient-reported outcomes after open preperitoneal inguinal hernia repair compared to anterior Lichtenstein repair: 10-year ACHQC analysis. Hernia 2023; 27:1139-1154. [PMID: 37553502 PMCID: PMC10533599 DOI: 10.1007/s10029-023-02852-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/19/2023] [Indexed: 08/10/2023]
Abstract
INTRODUCTION The Lichtenstein repair has been synonymous with "open" inguinal hernia repair (IHR) for 40 years. However, international guidelines have suggested that posterior mesh placement results in advantageous biomechanics and reduced risk of nerve-related chronic pain. Additionally, the use of local anesthetics has been shown to reduce postoperative pain and complication risks. An open transrectus preperitoneal/open preperitoneal (TREPP/OPP) repair combines posterior mesh placement with the use of local anesthetic and as such could be the ideal repair for primary inguinal hernia. Using the Abdominal Core Health Quality Collaborative (ACHQC) registry, we compared open anterior mesh with open posterior mesh repairs. METHODS We performed a propensity score matched analysis of patients undergoing open IHR between 2012 and 2022 in the ACHQC. After 1:1 optimal matching, both the TREPP/OPP and Lichtenstein cohorts were balanced with 451 participants in each group. Outcomes included patient-reported quality of life (QoL), hernia recurrence, and postoperative opioid use. RESULTS Improvement was seen after TREPP/OPP in EuraHS QoL score at 30 days (OR 0.558 [0.408, 0.761]; p = 0.001), and the difference persisted at 1 year (OR 0.588 [0.346, 0.994]; p = 0.047). Patient-reported opioid use at 30-day follow-up was significantly lower in the TREPP/OPP cohort (OR 0.31 [0.20, 0.48]; p < 0.001). 30-day frequency of surgical-site occurrences was significantly higher in the Lichtenstein repair cohort (OR 0.22 [0.06-0.61]; p = 0.007). There were no statistically significant differences in hernia recurrence risk at 1 year, or rates of postoperative bleeding, peripheral nerve injury, DVTs, or UTIs. CONCLUSION Our analysis demonstrates a benefit of posterior mesh placement (TREPP/OPP) over anterior mesh placement (Lichtenstein) in open inguinal hernia repair in patient-reported QoL and reduced opioid use.
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Affiliation(s)
- Divyansh Agarwal
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St., GRB 425, Boston, MA, 02114, USA.
| | - Tina Bharani
- Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA
| | - Nora Fullington
- Boston Hernia and Pilonidal Center, 20 Walnut Street, Suite 100, Wellesley, MA, 02481, USA
- Mass General Brigham - Newton Wellesley Hospital, Newton, MA, USA
| | - Lauren Ott
- Boston Hernia and Pilonidal Center, 20 Walnut Street, Suite 100, Wellesley, MA, 02481, USA
- Mass General Brigham - Newton Wellesley Hospital, Newton, MA, USA
| | - Molly Olson
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Benjamin Poulose
- Center for Abdominal Core Health, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jeremy Warren
- Department of Surgery, Division of Minimal Access, and Bariatric Surgery, Prisma Health Upstate, 701 Grove Rd, ST 3, Greenville, SC, 29605, USA
| | - Michael Reinhorn
- Boston Hernia and Pilonidal Center, 20 Walnut Street, Suite 100, Wellesley, MA, 02481, USA.
- Mass General Brigham - Newton Wellesley Hospital, Newton, MA, USA.
- Tufts University School of Medicine, Boston, MA, USA.
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Xu Z, Zhao Y, Fu X, Hu W, Zhao C, Ge C, Ye H, Chen C. Laparoscopic versus Open Inguinal Hernia Repair in Aging Patients: A Propensity Score Matching-Based Retrospective Study. Ther Clin Risk Manag 2023; 19:657-666. [PMID: 37575687 PMCID: PMC10422990 DOI: 10.2147/tcrm.s423307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023] Open
Abstract
Objective Although laparoscopic repair has been widely carried out and promoted due to its minimally invasive advantages, open surgery is still popular compared to elderly patients. This study aims to compare the outcomes of laparoscopic (LIHR) vs open repair of inguinal hernias (OIHR) in elderly patients. Methods A retrospective analysis of the database was performed to identify elderly patients, from January 2021 through December 2022, who underwent surgery for an inguinal hernia. After a 1:1 propensity score matching (PSM) with a caliper of 0.1 was conducted to balance potential bias, binary logistic regressions were used for categorical and continuous outcomes. Results After PSM, 78 pairs of elderly patients were enrolled in this study, and there were no significant differences in baseline between LIHR and OIHR groups. Compared to OIHR, univariable and multivariable logistic regression analysis showed that LIHR was independently affected for reducing intraoperative hemorrhage (OR = 0.06, 95% CI: 0.02-0.18, P < 0.001) and shortening postoperative hospitalization time (OR = 0.29, 95% CI: 0.15-0.57, P < 0.001) in elderly patients. Furthermore, LIHR (OR = 0.28, 95% CI: 0.14-0.57, P < 0.001) and age (OR = 0.89, 95% CI: 0.82-0.96, P = 0.002) were independent affecting factors for relieving postoperative pain. Meanwhile, no obvious differences were detected in postoperative complications [LIHR 7.7% (6/78) vs OIHR 14.1% (11/78), P = 0.199]. Conclusion LIHR was closely associated with reducing intraoperative hemorrhage and shortening postoperative hospitalization time. Whilst LIHR and age were independently affecting factors for relieving postoperative pain.
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Affiliation(s)
- Zipeng Xu
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
| | - Yong Zhao
- Department of General Surgery, Wuxi Rehabilitation Hospital, Wuxi, 214007, People’s Republic of China
| | - Xu Fu
- Department of General Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical school, Nanjing, 210008, People’s Republic of China
| | - Weidong Hu
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
| | - Chunlong Zhao
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
| | - Chen Ge
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
| | - Hui Ye
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, Nanjing, 210009, People’s Republic of China
- Department of Immunology, Ophthalmology & ORL, Complutense University School of Medicine, Madrid, 28040, Spain
| | - Chaobo Chen
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
- Department of General Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical school, Nanjing, 210008, People’s Republic of China
- Department of Immunology, Ophthalmology & ORL, Complutense University School of Medicine, Madrid, 28040, Spain
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