Quality of life after open versus laparoscopic preperitoneal mesh repair for unilateral inguinal hernias

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.

QUALITY OF LIFE USING EURAHS-QoL SCORES AFTER SURGICAL TREATMENT OF INGUINAL HERNIA: LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL (TAPP) AND LICHTENSTEIN TECHNIQUES

BACKGROUND

Results on quality of life after inguinal hernia surgery, such as esthetics, postoperative pain, period of absence from activities, and recurrence are a relevant topic since inguinal hernia affects 27% of men and 3% of women at some point in their lives, and should guide health policies to allocate resources more efficiently.

AIMS

To evaluate the quality of life in the late postoperative period of inguinal herniorrhaphy regarding recurrence, pain, esthetics, and restriction in activities, comparing the minimally invasive techniques - the transabdominal preperitoneal (TAPP) and the conventional Lichtenstein.

METHODS

A cross-sectional observational clinical study was conducted with the EuraHS-QoL questionnaire validated and translated into Portuguese, applied to patients after an average of 65 months postoperatively. Forty-five patients were assessed, 28 undergoing Lichtenstein and 17 undergoing TAPP. All were males aged between 18 and 87 years with a primary unilateral inguinal hernia. Recurrent or bilateral hernias, other concomitant abdominal wall hernias, patients who chose not to participate or who were not found, and female patients were excluded from the study.

RESULTS

Regarding the domains pain, restriction, and esthetics, there was no difference between the two groups when examining quality of life. Neither group presented recurrence in the studied period.

CONCLUSIONS

Both TAPP and Lichtenstein techniques presented similar results concerning quality of life when compared in the long-term.

What is the Best Inguinal Hernia Repair?

As the management of inguinal hernias have evolved over hundreds of years, so too has our paradigm of what constitutes the "best repair." To best answer what the ideal inguinal hernia repair is, the authors take an in-depth look at considerations to the patient, the provider, and the health care system.

Design of New Concept of Knitted Hernia Implant

A knitted implant, unilaterally modified with plasma-assisted chemical-vapor deposition (PACVD), and with a nano-layer of fluorine derivative supplementation, for reducing the risk of complications related to adhesions, and the formation of a thick postoperative scar was prepared. The biological evaluation of designed or modified medical devices is the main aspect of preclinical research. If such studies use a medical device with prolonged contact with connective tissue (more than 30 days), biocompatibility studies require a safety assessment in terms of toxicity in vitro and in vivo, allergenicity, irritation, and cancerogenicity, reproductive and developmental toxicity. The ultimate aspect of biological evaluation is biofunctionality, and evaluation of the local tissue response after implantation, resulting in the determination of all aspects of local biocompatibility with the implemented synthetic material. The implantation of PACVD-modified materials in muscle allows us to estimate the local irritation effect on the connective tissue, determining the risk of scar formation, whereas implantation of the above-mentioned knitted fabric into the abdominal wall, assists with evaluating the risk of fistula formation-the main post-surgical complications. The research aimed to evaluate the local reaction of the soft tissues after the implantation of the knitted implants modified with PACVD of the fluoropolymer in the nanostuctural form. The local effect that occurred during the implantation of the designed implants was quantitatively and qualitatively evaluated when PACVD unmodified (reference), and modified medical devices were implanted in the abdominal cavity (intra-abdominal position) for 12 or into the muscles for 56 weeks. The comparative semi-quantitative histological assessment included the severity of inflammatory cells (multinucleated cells, lymphocytes, plasma cells, macrophages, giant cells) and the tissue response (necrosis, neovascularization, fibrosis, and fat infiltration) on a five-point scale. The knitted implants modified by PACVD did not indicate cumulative tissue response when they were implanted in the muscle and intra-abdominally with direct contact with the viscera. They reduced local tissue reaction (score -2.71 after 56 weeks of the implantation) and internal organ adhesion (irritation score -2.01 and adhesion susceptibility -0.3 after 12 weeks of the implantation) compared with the reference (unmodified by PACVD) knitted implant, which had an identical structure and was made of the same source.

Lichtenstein versus transabdominal preperitoneal (TAPP) inguinal hernia repair for unilateral non recurrent hernia: A multicenter short term randomized comparative study of clinical outcomes

Background

The repair of inguinal hernia is still one of the most prevalent surgical procedures done worldwide. Among all repair techniques, open Lichtenstein repair is the most globally conducted. In the past few decades, laparoscopic technique for inguinal hernia repair has increased technical demand. Trans-abdominal pre-peritoneal (TAPP) technique is the main approach, which is featured by less postoperative pain and early recovery.

Objective

The current work is a short-term study to make a comparison between open Lichtenstein repair of inguinal hernia as well as laparoscopic trans-abdominal preperitoneal repair of inguinal hernia (TAPP) for unilateral non recurrent hernia regarding intraoperative, postoperative complications and hospital stay.

Patients and methods

The present prospective randomized study recruited 100 male subjects from General Surgery Department of Al-Azhar University Hospitals and Ain Shams university hospitals suffering from oblique inguinal hernia (unilateral non recurrent hernia) with an age above 18 years and good overall health, who were randomized into two groups: Group A: 49 cases were subjected to laparoscopic trans-abdominal pre-peritoneal repair (TAPP). Group B: 51 cases were subjected to open Lichtenstein repair.

Results

This study detected less post-operative pain day 0, day 1, day 7 and 1 month postoperatively. There was no significant difference at 6 months post-operatively.

Conclusion

Finally, we concluded that TAPP repair for inguinal hernia (unilateral non recurrent hernia) safer with less early post-operative pain. Also, it has fewer complications, with a significantly longer operative time.

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Inguinal hernia can be treated with either open surgical technique (Lichtenstein) or laparoscopic technique (transabdominal preperitoneal repair).

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TAPP repair for inguinal hernia safer with less early post-operative pain.

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There is no statistical difference as regard to surgical complications and post-operative recurrence.

Predictors of low quality of life after open inguinal hernia repair using the EuraHS-QoL score: prospective multicentric cohort study across 33 hospitals

PURPOSE

Evidence about factors influencing quality of life after inguinal hernia surgery is scarce. This study aimed to assess patient's Quality of Life (QoL) after open inguinal hernia repair and to identify predictors of low QoL at 3 months after surgery, to guide practice and inform patients at high risk.

METHODS

Prospective multicentric cohort study including consecutive patients undergoing elective open inguinal hernia repair in Portuguese hospitals (October-December 2019). The primary outcome was Quality of Life at 3 months after surgery, using the EuraHS-QoL score (higher score correlates with lower QoL). Low QoL was defined as the higher EuraHS-QoL score tertile and multivariate logistic regression was used to identify predictors.

RESULTS

893 patients were included from 33 hospitals. The majority were men [89.9% (800/891)], had unilateral hernias 88.7% (774/872) and the most common surgical technique was Lichtenstein's repair [52.9% (472/893)]. The median QoL score was 24 (IQR 10-40) before surgery and 2 (IQR 0-10) at 3 months after surgery, showing significant improvement (p < 0.001). After adjustment, low QoL at 3 months was associated with low preoperative QoL (OR 1.76, 95% CI 1.21-2.57, p = 0.003), non-absorbable mesh fixation (OR 1.64, 95% CI 1.12-2.41, p = 0.011), severe immediate postoperative pain (OR 2.90, 95% CI 1.66-5.11, p < 0.001) and minor postoperative complications (OR 2.23, 95% CI 1.30-3.84, p = 0.004).

CONCLUSION

This study supports the use of the EuraHS-QoL score preoperatively to inform consent. Although significant improvement in QoL is expected after surgery, high scores before surgery are associated with low postoperative QoL. Caution should be taken with non-absorbable mesh fixation and immediate postoperative pain control should be optimised.