Meta-analysis of randomized controlled trials comparing Lichtenstein and totally extraperitoneal laparoscopic hernioplasty in treatment of inguinal hernias

Comparing Laparoscopic Total Extraperitoneal and Lichtenstein Mesh Repair for Inguinal Hernias: A Focus on Patient Outcomes

BACKGROUND

This study aimed to evaluate post-operative outcomes by comparing factors such as post-operative pain, duration of hospitalization, time needed to resume normal and full activities, and complications between laparoscopic total extraperitoneal (TEP) and Lichtenstein tension-free mesh hernioplasty or repair (LMR) for inguinal hernias.

MATERIALS AND METHODS

A prospective study was conducted involving male patients undergoing either LMR or laparoscopic TEP mesh repair, with 30 patients in each group. The study assessed post-operative pain, duration of hospital stay, return to normal activities, and complications. Pain scores were monitored at regular intervals using a visual scale. Before discharge, patients' ability to perform self-care activities was evaluated using the Katz index of independence in activities of daily living. Outpatient follow-up was conducted on day 14, one month, three months, and six months post-surgery.

RESULTS

Post-operative pain scores were significantly higher among LMR patients compared to TEP patients until the 14th day post-surgery (p < 0.001). However, pain levels became comparable after that. There were no notable differences in pain scores between unilateral and bilateral hernias. TEP patients experienced significantly shorter hospital stays (p < 0.001) and quicker resumptions of self-care (p < 0.001), light work (p < 0.02), and full work (p < 0.03) compared to LMR patients.

CONCLUSION

Laparoscopic TEP repair offers advantages over Lichtenstein mesh repair in terms of reduced postoperative pain, shorter hospital stays, and faster recovery to normal activities. These findings can guide clinicians and patients in making informed decisions regarding hernia repair techniques.

Do we need mesh fixation at the laparoscopic hernia repair?

OBJECTIVE

With the development of laparoscopic treatment, widespread use of laparoscopy has become inevitable for the treatment of inguinal hernias, which is one of the most common ailments in surgical practice. Fixing or not fixing the mesh during laparoscopic repair remains a debate. In our study, we aimed to compare patients with and without mesh fixation in terms of postoperative pain, recurrence, complications, hospitalization and return to social life.

METHOD

The surgical technique to be performed was randomly determined, 81 patients whose data were kept prospectively and evaluated retrospectively were included in the study. Total extraperitoneal repair (TEP) was performed in all patients. While the mesh was not fixed in 50 patients, it was fixed with 2 tackers in 31 patients.

RESULTS

When the two groups of patients were compared, the group without mesh fixation was found to be superior in terms of postoperative pain, length of hospital stay and return to social life. There was no difference between the 2 groups in terms of complications and recurrence.

CONCLUSIONS

In the light of these findings, it is seen that TEP hernia repair can be performed safely without mesh fixation, although prospective randomized studies are needed.

Outcomes of Open Versus Laparoscopic Technique in Primary Inguinal Hernia Repair: A Retrospective Study

Inguinal hernia repair is one of the most common surgical procedures worldwide. In clinical practice, there are two different routes to repair inguinal hernias: laparoscopic mesh repair and open. Reducing the hernia and preventing recurrence remains the mainstay treatment option of both procedures. This study aims to compare postoperative outcomes and recurrence rates for patients who had primary, non-recurrent, laparoscopic, or open hernia repair in a single tertiary hospital. A retrospective cohort study was done on 468 patients. The study was conducted at King Abdulaziz University Hospital (KAUH) between 2013 and 2022. The distribution of our study population was divided into open hernia repair 378 participants (80.8%) while the rest did laparoscopic hernia repair 90 (19.2%). Operation duration in minutes was 107.158 ± 41.402 in the open hernia repair group and was noted to be significantly higher in the laparoscopic hernia repair group, with 142.811 ± 52.102 minutes p-value (0.000). The hospital length of stay was shown to be shorter in laparoscopic hernia repair (1.58 ±1.27) compared to open hernia repair (2.05±5.33). The most common postoperative complication was scrotal swelling, commonly associated with laparoscopic (5.55%) compared to 2.11% in open hernia repair. Open repair showed a risk of scrotal hematoma with a percentage of 0.52% compared to 0% in the laparoscopic method with a p-value (0.033). Hernia recurrence was non-related with any specific group, although noted to be higher in the laparoscopic group (7.77%), while in the open group (3.4%) with a p-value (0.081). The study conducted showed no alarming percentages for recurrence in either technique, open or laparoscopic, yet the open approach had a better outcome when it comes to scrotal pain and swelling post-operatively, chronic groin pain, and readmission rate as compared to laparoscopic technique, despite having a longer hospital stay. Future larger studies should be conducted to provide equal population inclusivity.

Laparoscopic versus Open Inguinal Hernia Repair in Aging Patients: A Propensity Score Matching-Based Retrospective Study

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.

Transinguinal preperitoneal (TIPP) vs endoscopic total extraperitoneal (TEP) procedure in unilateral inguinal hernia repair: a randomized controlled trial

PURPOSE

The Lichtenstein hernioplasty has long been seen as the gold standard for inguinal hernia repair. Unfortunately, this repair is often associated with chronic pain, up to 10-35%. Therefore, several new techniques have been developed, such as the transinguinal preperitoneal patch (TIPP) and the endoscopic total extraperitoneal (TEP) technique. Several studies showed beneficial results of the TIPP and TEP compared to the Lichtenstein hernioplasty; however, little is published on the outcome when comparing the TIPP and TEP procedures. This study aimed to evaluate outcomes after the TIPP vs the TEP technique for inguinal hernia repair.

METHODS

A single-center randomized controlled trial was carried out between 2015 and 2020. A total of 300 patients with unilateral inguinal hernia were enrolled and randomized to the TIPP- or TEP technique. Primary outcome was chronic pain (defined as any pain following the last 3 months) and quality of life, assessed with Carolinas comfort scale (CCS) at 12 months. Secondary outcomes were: wound infection, wound hypoesthesia, recurrence, readmission within 30 days, and reoperation.

RESULTS

A total of 300 patients were randomized (150 per group). After a follow-up of 12 months, we observed significantly less postoperative chronic groin pain, chronic pain at exertion, wound hypoesthesia, and wound infections after the TEP when compared to the TIPP procedure. No significant differences in quality of life, reoperations, recurrence rate, and readmission within 30 days were observed.

CONCLUSION

We showed that the TEP has a favorable outcome compared to the TIPP procedure, leading to less postoperative pain and wound complications, whereas recurrence rates and reoperations were equal in both the groups.

Extraperitoneal Laparoscopic Approach in Inguinal Hernia—The Ideal Solution?

Background: After more than 20 years since laparoscopy was proposed as a solution for one of the most common surgical pathologies, inguinal hernia, the choice of an intra- or extraperitoneal approach has remained a highly debated topic. Purpose and objectives: This study aimed at analyzing the feasibility of the extraperitoneal approach, by routine for this team/ and answering the question of whether this type of approach can be considered a safe one. Although indications for an intra- or extraperitoneal approach largely overlap, it may also be a matter of surgeon preference in choosing one technique. Methods: The study was retrospective, conducted on a group of 493 patients operated on for inguinal hernia in the clinic, by a single operating team, between January 2012 and March 2022. Results: It was proven that out of the 493 surgeries for inguinal hernia, 95.1% (n = 469) were operated upon by laparoscopic TEP (total extra peritoneal patch plasty approach); 1.62% (n = 8) by laparoscopic TAPP (transabdominal intraperitoneal); and 3.24% (n = 16) by the open, anterior approach (Lichtenstein). There were no intraoperative complications recorded in any of the procedures, while postoperative complications were found in 10.23% of cases (n = 48) in the extraperitoneal approach, and recurrences after the TEP approach were recorded in 0.40% of cases (n = 2). Conclusions: For correctly selected cases, TEP hernia surgery can be considered a safe and reliable approach.

Surgical outcomes of laparoscopic total extraperitoneal (TEP) inguinal hernia repair compared with Lichtenstein tension-free open mesh inguinal hernia repair: A prospective randomized study

Inguinal hernia repair is one of the most frequently performed surgery. The ideal procedure for inguinal hernia repair remains controversial. Open Lichtenstein tension-free mesh repair (LMR) is one of the most preferred open techniques with satisfactory outcomes. Laparoscopic approach in inguinal hernia surgery remains controversial, especially in comparison with open procedures. In this study, we have reported a comparison of laparoscopic total extraperitoneal (TEP) inguinal hernia repair with LMR. Postoperative pain, operative time, complications like seroma, wound infection, chronic groin pain, and recurrence rate were parameters to evaluate the outcome. One hundred seventy-four patients were included in the study by consecutive randomized prospective sampling. The patients were divided into 2 groups: group A, laparoscopic TEP inguinal hernia repair, and group B, LMR. The procedures were performed by experienced surgeons. The primary outcomes were evaluated based on postoperative pain and recurrence rate. Secondary outcomes considered for evaluation were operative time, complications like seroma, infection, and chronic groin pain. Severe pain was reported in group A (7.9%) compared to group B (15.1%), which was statistically significant (P < .001). Moderate pain was reported more in group B (70.9%) compared to group A (29.5%) (P < .001). The mean operative time in group A was 84.6 ± 32.2, which was significantly higher than that in group B, 59.2 ± 14.8. There was no major complication in both groups. The chronic pain postoperatively was significantly in higher number of patients in group B vs group A (22.09% vs 3.4%). The postoperative hospital stay period was significantly lesser for group A vs for group B (2.68 ± 1.52 vs 3.86 ± 6.16). Time duration taken to resume normal activities was significantly lower in group A (13.6 ± 6.8) vs (19.8 ± 4.6) in group B (P < .001). Although there is definite evidence of longer operative time and learning curve, laparoscopic TEP has added advantages like less postoperative pain, early resumption of normal activities, less chronic groin pain, and comparable recurrence rate compared to open Lichtenstein repair. Laparoscopic TEP can be performed with acceptable outcomes and less postoperative complications if performed by experienced hands.

Open versus laparoscopic repair of inguinal hernia: an overview of systematic reviews of randomised controlled trials

Background

Inguinal hernia has a lifetime incidence of 27% in men and 3% in women. Surgery is the recommended treatment, but there is no consensus on the best method. Open repair is most popular, but there are concerns about the risk of chronic groin pain. Laparoscopic repair is increasingly accepted due to the lower risk of chronic pain, although its recurrence rate is still unclear. The aim of this overview is to compare the risk of recurrence and chronic groin pain in laparoscopic versus open repair for inguinal hernia.

Methods

We searched Ovid MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for systematic reviews and meta-analyses. Only reviews of randomised controlled trials (RCTs) in adults published in English were included. Conference proceedings and editorials were excluded. The quality of the systematic reviews was assessed using the AMSTAR 2 checklist. Two outcomes were considered: hernia recurrence and chronic pain.

Results

Twenty-one systematic reviews and meta-analyses were included. Laparoscopic repair was associated with a lower risk of chronic groin pain compared with open repair. In the four systematic reviews assessing any laparoscopic versus any open repairs, laparoscopic repair was associated with a statistically significant (range: 26–46%) reduction in the odds or risk of chronic pain. Most reviews showed no difference in recurrence rates between laparoscopic and open repairs, regardless of the types of repair considered or the types of hernia that were studied, but most reviews had wide confidence intervals and we cannot rule out clinically important effects favouring either type of repair.

Conclusion

Meta-analyses suggest that laparoscopic repairs have a lower incidence of chronic groin pain than open repair, but there is no evidence of differences in recurrence rates between laparoscopic and open repairs.

Treatment of Inguinal Hernia: Systematic Review and Updated Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Despite the advent of innovative surgical platforms and operative techniques, a definitive indication of the best surgical option for the treatment of unilateral primary inguinal hernia remains unsettled. Purpose was to perform an updated and comprehensive evaluation within the major approaches to inguinal hernia.

METHODS

Systematic review and network meta-analyses of Randomized Controlled Trials (RCTs) compare Lichtenstein tension-free repair, laparoscopic transabdominal preperitoneal (TAPP) repair, and totally extraperitoneal repair (TEP). Risk Ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures while 95% Credible Intervals (CrI) were used to assess relative inference.

RESULTS

Thirty-five RCTs (7,777 patients) were included. Overall, 3,496 (44.9%) underwent Lichtenstein, 1,269 (16.3%) TAPP, and 3,012 (38.8%) TEP repair. The Visual Analogue Scale (VAS) was significantly lower for minimally invasive repair at <12-hour, 24 hours, and 48 hours. Postoperative chronic pain [TAPP vs. Lichtenstein (RR = 0.36; 95% CrI 0.15-0.81) and TEP vs. Lichtenstein (RR = 0.36; 95% CrI 0.21-0.54)] and return to work/activities [TAPP vs. Lichtenstein (WMD = -3.3; 95% CrI -4.9; -1.8) and TEP vs. Lichtenstein (WMD = -3.6; 95% CrI -4.9; -2.4)] were significantly reduced for minimally invasive approaches. Wound hematoma and infection were significantly reduced for minimally invasive approaches while no differences were found for seroma, hernia recurrence, and hospital length of stay.

CONCLUSIONS

Minimally invasive TAPP and TEP repair seem associated with significantly reduced early postoperative pain, return to work/activities, chronic pain, hematoma, and wound infection compared to the Lichtenstein tension-free repair. Hernia recurrence, seroma, and hospital length of stay seem similar across treatments.

Comparison of the effect of mesh-plug, Lichtenstein, transabdominal preperitoneal, and totally extraperitoneal hernia repair: A network meta-analysis

OBJECTIVE To compare Mesh-plug, Lichtenstein, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) repairs in regards to operation time, seroma, infection, and recurrence of inguinal hernia repair. METHODS Relevant literature was searched in the Cochrane Library, Pubmed, and Embase. Furthermore, the analysis of randomized controlled studies (RCTs) was performed using methods recommended by the Cochrane Collaboration. The main outcomes including operation time, seroma, infection, and recurrence were evaluated. RESULTS A total of 38 RCTs with 3255 patients were included in the meta-analysis. In addition, the comparison between Mesh-plug, Lichtenstein, TAPP, and TEP showed the differences were not significant regarding operation time, seroma, infection, and recurrence. CONCLUSIONS Meta-analysis suggests that Mesh-plug, Lichtenstein, TAPP, and TEP are comparable in the outcomes of hernia repair, such as operation time, seroma, infection, and recurrence.

Comparison of endoscopic surgery and Lichtenstein repair for treatment of inguinal hernias: A network meta-analysis

BACKGROUND

This study aimed to identify the best procedure for addressing inguinal hernias by comparing results after transabdominal preperitoneal (TAPP), totally extraperitoneal (TEP), and Lichtenstein repairs using a network meta-analysis.

METHODS

We conducted a systematic search of MEDLINE, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to September 1, 2018 for randomized controlled trials (RCTs) comparing the TAPP, TEP, and Lichtenstein procedures. The study outcome were the hernia recurrence, chronic pain, hematoma, seroma, wound infection, operation time, hospital stay, and return-to-work days.

RESULTS

Altogether, 31 RCTs were included in the meta-analysis. The results of this network meta-analysis showed there were no significantly differences among the 3 procedures in terms of hernia recurrence, chronic pain, hematoma, seroma, hospital stays. Lichtenstein had a shorter operation time than TAPP+TEP [MD (95%Crl)]: 12 (0.51-25.0) vs 18 (6.11-29.0) minutes, respectively) but was associated with more wound infections than TEP: OR 0.33 (95%Crl 0.090-0.81). Our network meta-analysis suggests that TAPP and TEP require fewer return-to-work days [MD (95%CI)]: - 3.7 (-6.3 to 1.3) vs -4.8 (-7.11 to 2.8) days.

CONCLUSION

Our network meta-analysis showed that there were no differences among the TAPP, TEP, and Lichtenstein procedures in terms of safety or effectiveness for treating inguinal hernias. However, TAPP and TEP could decrease the number of return-to-work days. A further study with more focus on this topic for inguinal hernia is suggested.

Randomized clinical trial comparing total extraperitoneal with Lichtenstein inguinal hernia repair (TEPLICH trial)

BACKGROUND

Chronic pain is reported after 10-35 per cent of inguinal hernia operations. The aim was to compare quality of life (QoL) after total extraperitoneal (TEP) and Lichtenstein hernia repairs in the setting of an RCT with operations performed by department-certified hernia surgeons.

METHODS

Men aged 30-75 years with an ASA grade I-II primary inguinal hernia were randomized to TEP or Lichtenstein repair. Primary endpoint was pain at 1 year assessed with the Inguinal Pain Questionnaire (IPQ). Clinical examination, IPQ, SF-36® and study-specific questions were recorded before surgery, and at 1 and 3 years.

RESULTS

Some 416 patients (202 TEP and 214 Lichtenstein) had surgery; 95·2 per cent completed 1-year and 89·9 per cent 3-year follow-up. At 1 year 'pain during last week' was reported by 6·9 per cent after TEP and by 9·8 per cent after Lichtenstein repair (P = 0·303), and 'pain right now' by 3·7 and 5·9 per cent respectively (P = 0·315). Favourable outcomes for TEP were duration of operation, 30-day complications, time to full recovery, foreign body sensation and sick leave. Groin sensory changes diminished after TEP but increased after Lichtenstein repair. Preoperative QoL was affected, especially in the physical subscales, but was restored to normal after surgery. At 1 and 3 years, 98·3 and 97·4 per cent respectively of the patients were satisfied; 1·6 per cent (6 of 374) suffered a recurrence at 3 years, four after TEP and two after Lichtenstein repair.

CONCLUSION

In the medium term, both TEP and Lichtenstein hernia repair had similar outcomes after 1 year, with high rates of patient satisfaction and low rates of chronic pain and recurrence. There were short-term advantages for pain and recovery rate after TEP repair. Registration number: NCT00803985 ( www.clinicaltrials.gov).

Lichtenstein Versus Total Extraperitoneal Patch Plasty Versus Transabdominal Patch Plasty Technique for Primary Unilateral Inguinal Hernia Repair: A Registry-based, Propensity Score-matched Comparison of 57,906 Patients

OBJECTIVE

Outcome comparison of the Lichtenstein, total extraperitoneal patch plasty (TEP), and transabdominal patch plasty (TAPP) techniques for primary unilateral inguinal hernia repair.

BACKGROUND

For comparison of these techniques the number of cases included in meta-analyses of randomized controlled trials is limited. There is therefore an urgent need for more comparative data.

METHODS

In total, 57,906 patients with a primary unilateral inguinal hernia and 1-year follow up from the Herniamed Registry were selected between September 1, 2009 and February 1, 2015. Using propensity score matching, 12,564 matched pairs were formed for comparison of Lichtenstein versus TEP, 16,375 for Lichtenstein versus TAPP, and 14,426 for TEP versus TAPP.

RESULTS

Comparison of Lichtenstein versus TEP revealed disadvantages for the Lichtenstein operation with regard to the postoperative complications (3.4% vs 1.7%; P < 0.001), complication-related reoperations (1.1% vs 0.8%; P = 0.008), pain at rest (5.2% vs 4.3%; P = 0.003), and pain on exertion (10.6% vs 7.7%; P < 0.001). TEP had disadvantages in terms of the intraoperative complications (0.9% vs 1.2%; P = 0.035). Likewise, comparison of Lichtenstein versus TAPP showed disadvantages for the Lichtenstein operation with regard to the postoperative complications (3.8% vs 3.3%; P = 0.029), complication-related reoperations (1.2% vs 0.9%; P = 0.019), pain at rest (5% vs 4.5%; P = 0.029), and on exertion (10.2% vs 7.8%; P < 0.001).

CONCLUSIONS

TEP and TAPP were found to have advantages over the Lichtenstein operation.

Total extraperitoneal endoscopic hernioplasty (TEP) versus Lichtenstein hernioplasty: a systematic review by updated traditional and cumulative meta-analysis of randomised-controlled trials

Background–purpose

Totally extraperitoneal (TEP) endoscopic hernioplasty and Lichtenstein hernioplasty are the most commonly used approaches for inguinal hernia repair. However, current evidence on which is the preferred approach is inconclusive. This updated meta-analysis was conducted to track the accumulation of evidence over time.

Methods

Studies were identified by a systematic literature search of the EMBASE, PubMed, Cochrane Library, and Google Scholar databases. Fixed- and random-effects models were used to cumulatively assess the accumulation of evidence over time.

Results

The TEP cohort showed significantly higher rates of recurrences and vascular injuries compared to the Lichtenstein cohort; [Peto Odds ratio (OR) = 1.58 (1.22, 2.04), p = 0.005], [Peto OR = 2.49 (1.05, 5.88), p = 0.04], respectively. In contrast, haematoma formation rate, time to return to usual activities, and local paraesthesia were significantly lower in the TEP cohort compared to the Lichtenstein cohort; [Peto OR = 0.26 (0.16, 0.41), p ≤ 0.001], [mean difference = − 6.32 (− 8.17, − 4.48), p ≤ 0.001], [Peto OR = 0.26 (0.17, 0.40), p ≤ 0.001], respectively.

Conclusions

This study, which is based on randomised-controlled trials (RCTs) of high quality, showed significantly higher rates of recurrences and vascular injuries in the TEP cohort than in the Lichtenstein cohort. In contrast, rate of postoperative haematoma formation, local paraesthesia, and time to return to usual activities were significantly lower in the TEP cohort than in the Lichtenstein cohort. Future multicentre RCTs with strict adherence to the standards recommended in the Consolidated Standards of Reporting Trials guidelines will shed further light on the topic.

Electronic supplementary material

The online version of this article (10.1007/s10029-019-02049-w) contains supplementary material, which is available to authorized users.

Open versus laparoscopic mesh repair of primary unilateral uncomplicated inguinal hernia: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

One standard repair technique for groin hernias does not exist. The objective of this study is to perform an update meta-analysis and trial sequential analysis to investigate if there is a difference in terms of recurrence between laparoscopic and open primary unilateral uncomplicated inguinal hernia repair.

METHODS

The reporting methodology conforms to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Randomised controlled trials only were included. The intervention was laparoscopic mesh repair (transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP)). The control group was Lichtenstein repair. The primary outcome was recurrence rate and secondary outcomes were acute and chronic post-operative pain, morbidity and quality of life.

RESULTS

This study included 12 randomised controlled trials with 3966 patients randomised to Lichtenstein repair (n = 1926) or laparoscopic repair (n = 2040). There were no significant differences in recurrence rates between the laparoscopic and open groups (odds ratio (OR) 1.14, 95% CI 0.51-2.55, p = 0.76). Laparoscopic repair was associated with reduced rate of acute pain compared to open repair (mean difference 1.19, CI - 1.86, - 0.51, p ≤ 0.0006) and reduced odds of chronic pain compared to open (OR 0.41, CI 0.30-0.56, p ≤ 0.00001). The included trials were, however, of variable methodological quality. Trial sequential analysis reported that further studies are unlikely to demonstrate a statistically significant difference between the two techniques.

CONCLUSION

This meta-analysis and trial sequential analysis report no difference in recurrence rates between laparoscopic and open primary unilateral inguinal hernia repairs. Rates of acute and chronic pain are significantly less in the laparoscopic group.

TEP for elective primary unilateral inguinal hernia repair in men: what do we know?

INTRODUCTION

Based on the new international guidelines for groin hernia management, there is no one surgical technique that is suited to all patient characteristics and diagnostic findings. Therefore, a tailored approach should be used. Here, a distinction must be made between primary unilateral inguinal hernia in men and in women, bilateral inguinal hernia, scrotal inguinal hernia, inguinal hernia following pelvic and lower abdominal procedures, patients with severe cardiopulmonary complications, recurrent inguinal hernias and incarcerated inguinal and femoral hernias. This paper now explores the relevant studies on TEP for elective primary unilateral inguinal hernia in men, which constitutes the most common indication for repair.

MATERIAL

A systematic search of the available literature was performed in February 2019 using Medline, PubMed, Scopus, Embase, Springer Link and the Cochrane Library. Only meta-analyses, systematic reviews, RCTs and comparative registry studies were considered. 117 publications were identified as relevant.

RESULTS

RCTs and comparative registry analyses demonstrated the advantages of TEP with regard to postoperative complications, complication-related reoperations, and postoperative and chronic pain compared with Lichtenstein repair for elective primary unilateral inguinal hernia repair in men. No relevant differences were found compared with TAPP. Mesh fixation is not needed in TEP, but heavyweight meshes result in a lower recurrence rate. Extraperitoneal bupivacaine analgesia vs placebo does not demonstrate any advantages, but drainage is advantageous for seroma prophylaxis. The risk of chronic pain is negatively influenced by small defects, younger patient age, preoperative pain, higher BMI, postoperative complications, higher ASA score and risk factors.

CONCLUSION

For the subgroup of elective primary unilateral inguinal hernia in men, accounting for a proportion of less than 50% of the total collective, advantages were identified for TEP compared with open Lichtenstein repair but not versus TAPP.

Transfascial suture versus tack fixation of mesh in totally extraperitoneal repair of inguinal hernia: A prospective comparative study

Purpose:

Among laparoscopic surgeries in inguinal hernias, totally extraperitoneal (TEP) repair has demonstrated favourable results in reduction of post-operative pain and mean operative times with early return to physical activity. We have done a prospective comparative study on two different techniques of mesh fixation, i.e., transfascial suture and tack fixation.

Materials and Methods:

It was a prospective, non-randomised comparative study done on inguinal hernia patients operated by TEP repair from October 2014 to September 2016. These data were compared in two techniques of mesh fixation (tack and transfascial sutures) in terms of post-operative complications, pain scores by visual analogue scale (VAS) and cost analysis of the procedure.

Results:

Our study on 69 total patients (44 tack fixation and 25 suture fixation group) revealed that mean VAS scores for post-operative pain were not having any statistically significant difference in the tack group versus suture group (2.42 ± 0.24 vs. 2.2 ± 0.24) at 24 h, but VAS scores in the follow-up period at 1 week, 1 month, 3 months and 6 months were 1.14 ± 0.33 versus 0.67 ± 0.27; 0.78 ± 0.24 versus 0.07 ± 0.06; 0.42 ± 0.17 versus 0.07 ± 0.06 and 0.5 ± 0.11 versus 0.07 ± 0.06, respectively, which showed significant difference at 1 and 3 months, suggesting less pain in the suture group. No significant difference was noted in other post-operative complications.

Conclusion:

Transfascial suture fixation of mesh in TEP repair of inguinal hernia can be a cost-effective procedure with a comparable safety profile as compared to tack fixation.

Laparoscopic versus Lichtenstein hernioplasty for inguinal hernias: a systematic review and Meta-analysis of randomized controlled trials

Background: This meta-analysis aimed to explore the safety and efficacy of Lichtenstein versus laparoscopic hernioplasty for inguinal hernias based on eligible randomized controlled trials (RCTs).Material and methods: We searched several electronic databases to identify eligible studies based on the index words updated to March 2018.We also searched related publication sources and only included eligible RCTs in the current analysis. Relative risk (RR) or mean difference (MD) along with 95% confidence interval (95% CI) were used for the main outcome of our analysis.Results: In total, 21 studies were included with 3772 patients in the laparoscopic group and 3910 patients in the Lichtenstein group. The results indicated that compared with the Lichtenstein group, the laparoscopic surgery group had significantly increased operative time. Besides, there was no significant difference in the rate of hematoma or seroma and complications between the two groups. However, compared with the Lichtenstein group, the laparoscopic group had a higher hernia recurrence rate, a lower incidence of chronic pain and a lower rate of wound infection, but no significant difference was found.Conclusion: The results demonstrated that laparoscopic repair reduced chronic pain and wound infection compared with Lichtenstein repair. But Lichtenstein could reduce the operative time and hernia recurrence.

Comparison of early and long term outcomes of open Lichtenstein repair and totally extraperitoneal herniorrhaphy for primary inguinal hernias

Background/aim

Inguinal hernia repair is one of the most common surgical procedures worldwide. There is still controversy over which method has the best postoperative results. The aim of this study was to compare early and late postoperative results of laparoscopic totally extraperitoneal herniorrhaphy (TEP) and open Lichtenstein herniorrhaphy (OLR).

Materials and methods

The study was conducted in a randomized prospective manner and it was concluded with 302 patients (147 cases in TEP group and 155 cases in OLR group). All procedures were performed by two experienced surgeons in both open and laparoscopic inguinal hernia repair.

Results

The groups were similar in terms of age, sex, and types of inguinal hernia according to Nyhuss classification. The mean operation time was shorter in TEP group with 49.2 ± 15.5 min vs 54.3 ± 14.6 min in OLR group (P = 0.004). The mean length of hospital stay was significantly shorter in TEP group (P = 0.001). The mean postoperative visual analogue scale score was significantly lower in TEP group. With a mean follow-up of 40.95 months, the recurrence rates were similar in both groups with a rate of 4.3%. In terms of chronic pain, TEP group has better results than OLR with 3.4% vs 25.2%, respectively (P = 0.001).

Conclusion

In experienced hands, TEP procedure has better early and late postoperative results than OLR, whereas recurrence rates are similar.

Feasibility of totally extraperitoneal (TEP) laparoscopic hernia repair in elderly patients

INTRODUCTION

Laparoscopic total extraperitoneal peritoneal (TEP) repair has become increasingly popular since its introduction. The purpose of this study is to establish the safety and feasibility of TEP in elderly patients compared to that in younger patients.

METHODS

The clinical records of patients who received TEP hernia repair from August 2007 to September 2016 were reviewed. The patients were categorized into two groups: younger than 70 and 70 years or older. The patient demographics, operative time, estimated blood loss, rate of open conversion, complications, length of hospital stay, rate of readmission, rate of recurrence were compared.

RESULTS

A total of 425 cases were documented. 317 (74.6%) patients were younger than 70 years and 108 (25.4%) were 70 years or older. The mean ages were 51.6 years in the younger group and 75.3 years in the older group. Co-morbidities (34.0% vs 72.2%, p = 0.000) and ASA score III and IV (4.1% vs. 6.5%, p value = 0.000) were more common in the elderly group. There were no significant differences between the two groups in the percentage of history of previous surgery in the lower abdominal region (23.9% vs 29.6%, p = 0.292), overall complications (7.2% vs 12.7%, p value = 0.177), and anesthesia-related complications (0% vs 1%, p value = 0.617). The operative time was similar between the two groups (54.3 vs 57.1 p = 0.220). The length of hospital stay (2.7 vs 3.0, p = 0.022) was longer in the elderly group.

CONCLUSIONS

Laparoscopic TEP hernia repair can be performed safely in elderly patients without differences in perioperative complications and recurrence rate compared to that in a younger population despite a longer hospital stay.

Contemporary Factors Associated with the Use of Laparoscopy for Inguinal Hernia Repair Among Department of Defense Beneficiaries

INTRODUCTION

The factors that contribute to variation in utilization of laparoscopic inguinal hernia repair are unknown. We sought to determine the current usage patterns of laparoscopic and open surgery in the elective repair of uncomplicated unilateral inguinal hernia in a large population with universal health care coverage comprised of Department of Defense (DoD) beneficiaries.

MATERIALS AND METHODS

The DoD Military Health System Data Repository (MDR) tracks health care delivered to a universally insured population of active/reserve/retired members of the U.S. Armed Services and their dependents. The MDR was queried for elective unilateral inguinal hernia repair among adult patients between 2008 and 2014. The primary outcome was laparoscopic (vs. open) approach to hernia repair. We conducted univariable and multivariable analyses of patient- and systems-level factors associated with approach to inguinal hernia repair. This research was approved by our institutional review board prior to commencement of the study and need for informed consent was waived given the design of this study.

RESULTS

Among 37,742 elective uncomplicated unilateral inguinal hernia repairs, 35% (n = 13,114) were performed laparoscopically. In 2014, 40% of inguinal hernia repairs were performed laparoscopically, compared with 27% of repairs in 2008 (P < 0.01). In multivariable analysis, laparoscopic hernia repair was more likely for male patients (OR = 1.38, 95% CI = 1.23-1.54, P < 0.01), military (vs. civilian) institutions (OR = 1.34, 95% CI = 1.28-1.41, P < 0.01), active-duty officers (vs. active-duty enlisted; OR = 1.21, 95% CI = 1.12-1.30, P < 0.01), and more recent year of surgery (P < 0.01). Laparoscopic repair was significantly less likely among patients with greater than one comorbidity (vs. none; OR = 0.68, 95% CI = 0.61-0.76, P < 0.01).

CONCLUSION

In a large, universally insured population of military service members and their dependents, laparoscopic inguinal repair is increasingly used and was preferred over open repair for younger, healthier, active-duty patients and those treated within the military (vs. non-military) care system.

Current Concepts of Inguinal Hernia Repair

With more than 20 million patients annually, inguinal hernia repair is one of the most often performed surgical procedures worldwide. The lifetime risk to develop an inguinal hernia is 27-43% for men and 3-6% for women. In spite of all advances, 11% of all patients suffer from a recurrence and 10-12% from chronic pain following primary inguinal hernia repair. By developing evidence-based guidelines and recommendations, the international hernia societies aim to improve the outcome of inguinal hernia repair due to standardization of care. From a total of more than 100 different repair techniques for inguinal and femoral hernias, classified as tissue repair, open mesh repair, and laparo-endoscopic mesh repair, the new International Guidelines of the Hernia-Surge Group only recommend the totally extraperitoneal patch plasty (TEP), transabdominal preperitoneal patch plasty (TAPP), and Lichtenstein techniques. Since a generally accepted technique suitable for all inguinal hernias does not exist, surgeons should provide both an anterior open (Lichtenstein) and a posterior laparo-endoscopic (TEP or TAPP) approach option. The guidelines strongly recommend that surgeons tailor the treatment of inguinal hernias based on expertise, local/national resources, and patient- and hernia-related factors. A tailored approach in inguinal hernia repair should pay heed to the patient- and hernia-related factors, unilateral hernia in men and women, bilateral hernia, recurrent hernia, scrotal hernia, previous pelvic and lower abdominal surgery, severe cardiac or pulmonary comorbidities, and incarcerated hernia.

[Inguinal and femoral hernia surgery : Open mesh procedure. Video article]

There are several techniques for repair of symptomatic inguinal and femoral hernias. There is an increased acceptance and tendency favoring minimally invasive procedures, such as plug or transinguinal preperitoneal mesh prosthesis (TIPP) and endoscopic procedures, such as totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repair. In the present review the classical techniques of Irving L. Lichtenstein (1986) and Jean Rives (1965), two indispensable procedures, are presented and the results from the literature are discussed. The videos show the repair of three interesting and complex cases. The surgical techniques are demonstrated in detail with the help of a video of the operation and which is available online. It is essential that each hernia surgeon should have proficiency in performing both procedures in order to be able to counsel patients and tailor the procedure according to the clinical findings.

Factors associated with hernia recurrence after laparoscopic total extraperitoneal repair for inguinal hernia: a 2-year prospective cohort study

BACKGROUND

Laparoscopic total extraperitoneal repair (TEP) of inguinal hernia has been associated with higher rates of recurrence compared to open methods. The aim of the present study was to determine independent risk factors for recurrence within 2 years after TEP.

METHODS

This was a single-centre prospective cohort study with consecutive inclusion of patients undergoing inguinal hernia repair from 2010 to 2014. Systematic follow-up was conducted 6 months and 2 years postoperatively. Risk factors for recurrence after 2 years were analysed in univariate and multivariate analyses.

RESULTS

A total of 1194 patients underwent TEP for inguinal or femoral hernia in the study period, of which 1047 were eligible for analyses. After 2 years, 56 (5.3%) patients had presented with recurrence. The following factors were associated with recurrence in univariate analyses: body mass index (BMI) >30 (HR 3.64; p = 0.011), medial vs. lateral hernia (HR 2.37; p = 0.004), repair of recurrent hernia vs. primary repair (HR 2.12; p = 0.049), and length of stay >1 day (HR 1.77; p = 0.043). In multivariate analyses, factors independently associated with recurrence after 2 years were BMI >30 (HR 3.74; p = 0.026) and medial vs. lateral hernia (HR 2.39; p = 0.004).

CONCLUSION

The recurrence rate after TEP is higher than reported after open hernia repair. Attempts to decrease the rate should be persuaded. Good surgical technique with precise dissection and correct placement of the mesh, especially in medial hernias and obese patients, may be key points to improve outcomes after TEP.

Laparoscopic Total Extraperitoneal Hernia Repair Outcomes

Background and Objectives:

Laparoscopic inguinal hernia repair has become increasingly popular as an alternative to open surgery. The purpose of this study was to evaluate the safety and effectiveness of the laparoscopic total extraperitoneal procedure with the use of staple fixation and polypropylene mesh.

Methods:

A retrospective chart review examined outcomes of 1240 laparoscopic hernia operations in 783 patients, focusing on intraoperative and early postoperative complications, pain, and time until return to work and normal physical activities.

Results:

There were no intraoperative complications in this series; 106 patients experienced early postoperative complications across 8 evaluated categories: urinary retention (4.1%), seroma (3.0%), testicular/hemiscrotal swelling (1.9%), testicular atrophy (0%), hydrocele (0.6%), mesh infection (0.1%), and neurological symptoms (transient, 1.0%; persistent, 0.2%). Patients used an average of 5.6 Percocet pills after the procedure, and mean times until return to work and normal activities, including their routine exercise regimen, were 3.0 and 3.8 days, respectively.

Conclusion:

Complication rates and convalescence times were considered equivalent or superior to those found in other studies assessing both laparoscopic and open techniques. The usage of multiple Endostaples did not result in increased neurologic complications in the early postoperative period when compared with findings in the literature. In the hands of an experienced surgeon, total extraperitoneal repair is a safe, effective alternative to open inguinal hernia repair.

Surgical risk factors for recurrence in inguinal hernia repair - a review of the literature

Despite all the progress made in inguinal hernia surgery driven by the development of meshes and laparoendoscopic operative techniques, the proportion of recurrent inguinal hernias is still from 12% to 13%. Recurrences can present very soon after primary inguinal hernia repair generally because of technical failure. However, they can also develop much later after the primary operation probably due to patient-specific factors. Supported by evidence-based data, this review presents the surgical risk factors for recurrent inguinal hernia after the primary operation. The following factors are implicated here: choice of operative technique and mesh, mesh fixation technique, mesh size, management of medial and lateral hernia sac, sliding hernia, lipoma in the inguinal canal, operating time, type of anesthesia, participation in a register database, femoral hernia, postoperative complications, as well as the center and surgeon volume. If these surgical risk factors are taken into account when performing primary inguinal hernia repair, a good outcome can be expected for the patient. Therefore, they should definitely be observed.

Comparison of mesh fixation and non-fixation in laparoscopic totally extraperitoneal inguinal hernia repair

PURPOSE

The purpose of this study was to compare laparoscopic total extraperitoneal (TEP) hernia repair procedures with or without mesh fixation for non-recurrent inguinal hernia.

METHODS

100 male patients with non-recurrent inguinal hernia (62 unilateral and 38 bilateral) were included in the study. The patients were randomly assigned to either the mesh fixation group (n = 50) or the mesh non-fixation group (n = 50). The operative and follow-up data of the two groups were analyzed and compared in terms of recurrence rates, postoperative pain, length of hospital stay, and postoperative changes in testicular arterial blood flow.

RESULTS

Pain scores were significantly higher in the mesh fixation group prior to discharge and at the 1st postoperative month (p = 0.034 and 0.001, respectively). Necessity to use narcotic analgesics was higher in the fixation group prior to discharge (p = 0.025). Urinary retention was significantly more frequent in the fixation group than in the non-fixation group. (p = 0.007). The mean operative time and length of hospital stay were similar in both groups. Preoperative and postoperative measurements of testicular arterial blood flow showed a substantial but not statistically significant difference for the frequency of impairment (14.2% in the fixation group and 5.8% in the non-fixation group) (p = 0.176). At long-term follow-up, no recurrence and no nerve injury were determined.

CONCLUSION

Fixation of the mesh to the abdominal wall has been associated with various postoperative complications for no additional benefit in lowering recurrence rates. For non-recurrent inguinal hernia, non-fixation of the mesh is safe and reliable. Further studies with larger sample sizes are necessary for subgroup analyses.

A prospective randomized comparison of testicular functions, sexual functions and quality of life following laparoscopic totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) inguinal hernia repairs

BACKGROUND

There is very scant literature on the impact of inguinal hernia mesh repair on testicular functions and sexual functions following open and laparoscopic repair. The present randomized study compares TAPP and TEP repairs in terms of testicular functions, sexual functions, quality of life and chronic groin pain.

METHODS

This study was conducted from April 2012 to October 2014. A total of 160 patients with uncomplicated groin hernia were randomized to either trans-abdominal pre-peritoneal (TAPP) repair or totally extra-peritoneal (TEP) repair. Testicular functions were assessed by measuring testicular volume, testicular hormone levels preoperatively and at 3 months postoperatively. Sexual functions were assessed using BMSFI, and quality of life was assessed using WHO-QOL BREF scale preoperatively and at 3 and 6 months postoperatively. Chronic groin pain was evaluated using the VAS scale at 3 months, 6 months and at 1 year.

RESULTS

The median duration of follow-up was 13 months (range 6-18 months). The mean preoperative pain scores (p value 0.35) as well as the chronic groin pain were similar between TEP and TAPP repairs at 3 months (p value 0.06) and 6 months (p value 0.86). The testicular resistive index and testicular volume did not show any significant change at follow-up of 3 months (p value 0.9) in the study population. No significant difference was observed in testicular resistive index and testicular volume when comparing TEP and TAPP groups at at follow-up of 3 months (p value >0.05). There was a statistically significant improvement in the sexual drive score, erectile function and overall satisfaction over the follow-up period following laparoscopic inguinal hernia repair. However, sexual function improvement was similar in patients undergoing both TEP and TAPP repairs. All the domains of quality of life in the study population showed a significant improvement at a follow-up of 3 and 6 months. Subgroup analysis of all the domains of quality of life in both TAPP and TEP groups showed a similar increment as in the study population (p value <0.001); however, the mean scores of all the domains were comparable between the two subgroups (p value >0.05), preoperatively and 3 and 6 months follow-up.

CONCLUSIONS

Laparoscopic groin hernia repair improves the testicular functions, sexual functions and quality of life, but TEP and TAPP repairs are comparable in terms of these long-term outcomes.

Cost-conscious decisions in the timing of operation for minimally symptomatic inguinal hernias in male patients

BACKGROUND

Expectant management (EM) and early open repair (OR) are safe and effective as initial management strategies for minimally symptomatic inguinal hernia in male patients. Extended follow-up of patients in EM protocols have shown that most patients will eventually require repair, but it is not clear which strategy is less costly over the long term.

METHODS

We constructed a mathematical model to compare 3rd-party payer expenditures for EM vs OR or laparoscopic repair in a simulated cohort of patients with inguinal hernia. Cohort characteristics and expenditures were calibrated to recent randomized trials that reported initial follow-up and expenditures at 2 years and long-term crossover rates from EM to OR.

RESULTS

Cost comparisons between OR and EM are sensitive to direct long-term costs of inpatient and outpatient care, the likelihood of crossover from EM to operation, cost differences between OR and laparoscopic repair, and the net present value of longer-term costs.

CONCLUSIONS

Our findings suggest that short-term costs of EM are less than those of OR and Lap-R, but early OR provides the highest long-term savings.

Comparison of peritoneal closure techniques in laparoscopic transabdominal preperitoneal inguinal hernia repair: a prospective randomized study

PURPOSE

We aimed to compare tacker and suture techniques for peritoneal closure with respect to patient outcomes.

METHODS

A total of 64 patients were included in the study, 32 being in the tacker group and 32 in the suture group. All patients underwent laparoscopic TAPP inguinal hernia repair. Both groups were compared with respect to age, sex, duration of peritoneal closure and the operation, hernia type, the number of tackers used for mesh fixation, postoperative complication rate, visual analogue scale (VAS) scores on 1st, 7th, and 30th days, duration of follow-up, and recurrence rates.

RESULTS

Duration of peritoneal closure and the operation was significantly shorter in the tacker group compared to the suture group (p < 0.001, p = 0.008, respectively). Statistical analysis with the two-way analysis of variance method revealed that mesh fixation with one or two tackers did not influence postoperative pain. VAS 1 was significantly lower in patients with peritoneal closure with suture compared to the patients undergoing peritoneal closure with tacker (p = 0.027). VAS 7 and VAS 30 were lower for peritoneal closure with suture versus tacker, although the difference did not reach statistical significance (p = 0.064, p = 0.294, respectively). We observed no recurrence at an average of 21-month follow-up.

CONCLUSIONS

Tacker and suture appeared to have a comparable safety for peritoneal closure in laparoscopic TAPP inguinal hernia operation. It can be suggested that peritoneal closure with tacker increased short-term pain, independent of the number of tackers used for mesh fixation. Long-term pain was similar in both groups.