Endoscopic Totally Extraperitoneal Inguinal Hernioplasty Under Spinal Anesthesia

Effect of general and spinal anaesthesia on post-operative wound healing during laparoscopic totally extraperitoneal inguinal hernia repair: A meta-analysis

Totally extraperitoneal prosthetic (TEP) is a surgical technique for the treatment of hernia. The purpose of this research is to compare the efficacy of both general anaesthesia and spine anaesthesia for TEP herniorrhaphy. The number of patients who received TEP operations related to the injury from 2008 to 2022 was counted in this study. Patients with TEP operation were classified into general anaesthesia and spine anaesthesia. In this research, 186 related articles were found in the data base, and in the end, 8 were analysed. This study involved 2452 cases of hernia. The data of the operation time, the infection of the wound and the bleeding of the wound were analysed. The analysis of the data was done with RevMan 5.3. Results indicated that there was no significant difference between general anaesthesia and spinal anaesthesia in post-surgical rates for post-operative wound infection (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.49-1.83; p = 0.86); In general anaesthesia, there was no difference in the risk of post-operative wound haematoma when compared with those treated with spinal anaesthesia (OR, 2.96; 95% CI, 0.37-23.69; p = 0.31). In the seven trials, there was no difference in the duration of the surgery between the general anaesthetic and the spinal anaesthesia group (mean difference, -1.44; 95% CI, -4.11 to 1.22; p = 0.29). Data from the available meta-analysis indicate that there is no difference in the risk of post-operative wound infection or wound haematoma when treated with TEP.

Meta-Analysis of Spinal Anesthesia Versus General Anesthesia During Laparoscopic Total Extraperitoneal Repair of Inguinal Hernia

OBJECTIVES

To evaluate comparative outcomes of spinal anesthesia (SA) and general anesthesia (GA) during laparoscopic total extraperitoneal (TEP) repair of inguinal hernia.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Postoperative pain assessed by visual analogue scale (VAS), individual and overall perioperative morbidity, procedure time and time taken to normal activities, were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models.

RESULTS

We identified 5 comparative studies reporting a total of 1518 patients (2134 hernia) evaluating outcomes of laparoscopic TEP inguinal hernia repair under SA (n=1277 patients, 1877 hernia) or GA (n=241 patients, 257 hernia). SA was associated with significantly lower post-operative pain assessed by VAS at 12 hours [mean difference (MD): -0.32; 95% confidence interval (CI), -0.45 to -0.20; P<0.0001] and shorter time to normal activities (MD: -0.30; 95% CI, -0.48 to -0.11; P=0.002) compared with GA. However, it significantly increased risk of urinary retention [odds ratio (OR): 4.02; 95% CI, 1.32-12.24; P=0.01], hypotension (OR: 3.97; 95% CI, 1.57-10.39; P=0.004), headache (OR: 7.65; 95% CI, 1.98-29.48, P=0.003), and procedure time (MD: 3.82; 95% CI, 1.22-6.42; P=0.004). There was no significant difference in VAS at 24 hours (MD: 0.06; 95% CI, -0.06 to 0.17; P=0.34), seroma (OR: 1.54; 95% CI, 0.73-3.26; P=0.26), wound infection (OR: 1.03; 95% CI, 0.45-2.37; P=0.94), and vomiting (OR: 0.84; 95% CI, 0.39-1.83; P=0.66) between the 2 groups. There was a nonsignificant decrease in overall morbidity in favor of GA (OR: 1.84; 95% CI, 0.77-4.40; P=0.17) which became significant following sensitivity analysis (OR: 2.59; 95% CI, 1.23-5.49; P=0.01).

CONCLUSIONS

Although TEP inguinal hernia repair under SA may reduce pain in early postoperative period, it seems to be associated with increased postoperative morbidity and longer procedure time. It may be an appropriate anesthetic modality in selected patients who are considered high risk for GA. Higher level of evidence is needed.

Comparision of Dexmedetomidine and Propofol in Patients Undergoing Laparoscopic Cholecystectomy Under Spinal Anesthesia

Background:

Spinal anesthesia (SA) with sedation is considered to be an alternative to general anesthesia for laparoscopic cholecystectomy (LC) in high-risk patients. Ketamine in analgesic dose with propofol or dexmedetomidine infusion provides titratable sedation, hemodynamic stability, and minimum respiratory depression without psychomimetic effects.

Aim:

To compare the efficacy of ketamine–dexmedetomidine and ketamine-propofol combination in relation to sedation, analgesia, hemodynamic effects, and perioperative side effects.

Settings and Design:

This was a prospective, randomized single-blind comparative study comprising 100 American Society of Anesthesiologists I, II, and III patients posted for LC.

Materials and Methods:

Patients were randomized into two groups of 50 patients each. Group KP (ketamine + propofol) received intravenous (i.v.) bolus of injection ketamine 0.5 mg.kg ⁻¹ and propofol infusion at 3 mg.kg ⁻¹.h ⁻¹. Group KD (ketamine + dexmedetomidine) received i.v. bolus of injection ketamine 0.5 mg.kg ⁻¹ and dexmedetomidine infusion at 0.4 μg.kg ⁻¹.h ⁻¹. Parameters observed were vitals, perioperative side effects, time to first rescue analgesia, and return of consciousness.

Statistical Analysis:

Student's independent t-test was employed for comparing continuous variables. Chi-square test or Fisher's exact test, whichever appropriate, was applied for comparing categorical variables.

Results:

Duration of analgesia was longer in KD Group (191.2 vs. 173.5 min), and time to regain consciousness was faster in KP Group (14.9 vs. 20.4 min).

Conclusion:

Both the techniques of sedation are feasible, safe, and comparable, except the duration of analgesia and time to regain consciousness which was longer in KD Group.

Hemodynamic effects of anesthesia type in patients undergoing laparoscopic transabdominal preperitoneal inguinal hernia repair under spinal vs general anesthesia

PURPOSE

General anesthesia has been used as a standard type of anesthesia for laparoscopic inguinal hernia repair by the transabdominal preperitoneal (TAPP) approach, regional anesthesia being occasionally used in high-risk patients. We had previously designed a controlled randomized trial, comparing spinal with general anesthesia in non-high-risk patients undergoing TAPP inguinal hernia repair. Our results suggested that spinal anesthesia offers some advantages in postoperative pain and additional opioid consumption during the early postoperative period. In the context of this trial, hemodynamic effects of each type of anesthesia are presented.

METHODS

Seventy patients, undergoing elective TAPP inguinal hernia repair were randomized to either general or spinal anesthesia. Data regarding patients' hemodynamic status during the procedure under general or spinal anesthesia were collected, measuring systolic blood pressure (SBP), diastolic blood pressure (SBP), mean arterial pressure (MAP) and heart rate (HR).

RESULTS

There was no significant effect of anesthesia type on systolic, diastolic and mean arterial pressure values after induction of anesthesia and induction of pneumoperitoneum, respectively. There was a significant effect on heart rate values after induction of anesthesia and induction of pneumoperitoneum, respectively.

CONCLUSIONS

Spinal anesthesia is as effective as general anesthesia concerning hemodynamic stability and seems to provide a better result in maintaining hemodynamic stability with fewer fluctuations in blood pressure and mild alterations in heart rate values during TAPP inguinal hernia repair.

Open mesh and laparoscopic total extraperitoneal inguinal hernia repair under spinal and general anesthesia

INTRODUCTION

Mesh placement is the main standard in repair of inguinal hernia, and laparoscopic repair is the standard of care via spinal, epidural, or combined anesthesia. Here, we compared open and laparoscopic total extraperitoneal (TEP) repairs under general (GA) and spinal anesthesia (SA).

METHODS

Inguinal hernia patients (n=440) were analyzed retrospectively. There were four groups: Group 1 was TEP under GA (TEP-GA) (n=111); Group 2 was open mesh repair (OM) under SA (n=116) (OM-SA); Group 3 was open mesh repair under GA (n=117) (OM-GA); Group four was TEP under SA (n=96) (TEP-SA). The age, body mass index, duration of operation, hospital stay, postoperative Visual Analog Scale scores, recurrence, postoperative pain, urinary retention, headache, and patient satisfaction were all recorded.

RESULTS

There was no significant difference in terms of hypotension, vomiting, seroma and scrotal edema, recurrence, and wound infection incidence between the groups. However, the operation duration, hospital stay period, headache, urinary retention, postoperative Visual Analog Scale scores, chronic pain, and patient satisfaction showed significant differences between groups.

CONCLUSION

Laparoscopic TEP hernia repair is a safe and effective method along with its advantages of shorter hospital stay, less recurrence, less postoperative pain, higher patient satisfaction, and similar postoperative complication rates. SA has the disadvantage of higher incidence of headache and urinary retention compared to GA.

Spinal anesthesia is safe in laparoscopic total extraperitoneal inguinal hernia repair. A retrospective clinical trial

Introduction

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is an effective and safe method for the treatment of inguinal hernia. There are very few studies on regional anesthesia methods in TEP surgery.

Aim

To compare TEP inguinal hernia repair performed when the patient was treated under spinal anesthesia (SA) with that performed under general anesthesia (GA).

Material and methods

All total of 80 patients were studied between December 2015 and March 2017. Hyperbaric bupivacaine and fentanyl were used for SA, to achieve a sensorial level of T3. Propofol, sevoflurane, rocuronium, fentanyl, and tracheal intubation were used for GA. Intraoperative events related to SA, surgical times, intra- and postoperative complications, and pain scores were recorded.

Results

The mean operative time in the SA TEP group was 70.2 ±6.7 min, which was significantly longer than the mean operative time in the GA TEP group of 67.2 ±6.2 min (p < 0.038). The mean pain scores in the SA TEP group were 0.23 ±0.42 at the first hour, 1.83 ±0.64 at 6 h and 1.28 ±0.45 at 24 h. These scores were significantly lower than the corresponding scores of 5.18 ±0.84 (p < 0.001), 2.50 ±0.55 (p < 0.001) and 1.58 ±0.55 in the GA TEP group. Generally, patients were more satisfied with SA than GA (p < 0.004).

Conclusions

Spinal anesthesia TEP is significantly less painful in the early postoperative period, leading to earlier ambulation than GA TEP. Additionally, SA TEP results in significantly less need for analgesics and better patient satisfaction results. SA TEP seems to be a better alternative than the existing GA TEP.

Spinal versus general anesthesia for transabdominal preperitoneal (TAPP) repair of inguinal hernia: Interim analysis of a controlled randomized trial

BACKGROUND

General anesthesia has been used as standard for laparoscopic hernia repair by the transabdominal preperitoneal (TAPP) approach. Regional anesthesia has been occasionally applied in high risk patients where general anesthesia is contraindicated. This randomized clinical trial compares spinal anesthesia with general anesthesia for TAPP inguinal hernia repair in non-high risk patients.

METHODS

Seventy adult American Society of Anesthesiologists I, II and III patients undergoing elective TAPP inguinal hernia repair were randomized to either general or spinal anesthesia.

RESULTS

Postoperative morphine consumption was significantly less immediately postoperatively (p < 0.001) in the spinal anesthesia group. Postoperative pain was also significantly decreased within the first 8 h postoperatively (p < 0.05) in the spinal anesthesia group.

CONCLUSIONS

Spinal anesthesia offers some advantages in patient analgesia during the early postoperative period after TAPP inguinal hernia repair and can be proposed as an effective alternative method of anesthesia for TAPP repair.

Laparoscopic total extraperitoneal repair under spinal anesthesia versus general anesthesia: a randomized prospective study

Background

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is a well-known approach to inguinal hernia repair that is usually performed under general anesthesia (GA). To date, no reports compare the efficacy of spinal anesthesia (SA) with that of GA for laparoscopic hernia repairs. The purpose of this study was to compare the surgical outcome of TEP inguinal hernia repair performed when the patient was treated under SA with that performed under GA.

Materials and methods

Between July 2015 and July 2016, 50 patients were prospectively randomized to either the GA TEP group (Group I) or the SA TEP group (Group II). Propofol, fentanyl, rocuronium, sevoflurane, and tracheal intubation were used for GA. Hyperbaric bupivacaine (15 mg) and fentanyl (10 µg) were used for SA to achieve a sensorial level of T₃. Intraoperative events related to SA, operative and anesthesia times, postoperative complications, and pain scores were recorded. Each patient was asked to evaluate the anesthetic technique by using a direct questionnaire filled in 3 months after the operation.

Results

All the procedures were completed by the allocated method of anesthesia as there were no conversions from SA to GA. Pain was significantly less for 1 h (P<0.0001) and 4 h (P=0.002) after the procedure for the SA and GA groups, respectively. There was no difference between the two groups regarding complications, hospital stay, recovery, or surgery time. Generally, patients were more satisfied with SA than GA (P<0.020).

Conclusion

TEP inguinal hernia repair can be safely performed under SA, and SA was associated with less postoperative pain, better recovery, and better patient satisfaction than GA.

Preemptive analgesia of oral clonidine during subarachnoid block for laparoscopic gynecological procedures: A prospective study

BACKGROUND

Preemptive analgesia is known modality to control the peri-operative pain. The present study was aimed to evaluate the effects of oral clonidine on subarachnoid block characteristics, hemodynamic changes, sedation and respiratory efficiency in patients undergoing laparoscopic gynecological procedures.

PATIENTS AND METHODS

A total of 64 adult consenting females of American Society of Anesthesiologist physical status I and II were randomized double blindly into two groups of 32 patients each. Patients in the clonidine group received oral clonidine (100 μg) and patients of the control group received placebo capsule, 90 min before subarachnoid block with 0.5% hyperbaric bupivacaine (3.5 ml). The onset of sensory and motor block, maximum cephalic sensory level and regression times of sensory and motor blockade were assessed. Intra-operative hemodynamic changes, respiratory efficiency, shoulder pain and sedation score were recorded. The other side-effects, if any were noted and managed.

RESULTS

The onset of sensory blockade was earlier in patients of clonidine group with prolonged duration of analgesia (216.4 ± 23.3 min vs. 165.8 ± 37.2 min, P < 0.05), but no significant difference was observed on motor blockade between groups. The hemodynamic parameters and respiratory efficiency were maintained within physiological limits in patients of clonidine group and no patient experienced shoulder pain. The Ramsey sedation score was 2.96 ± 0.75. In the control group, 17 patients experienced shoulder pain, which was effectively managed with small doses of ketamine and 15 patients required midazolam for anxiety.

CONCLUSION

Premedication with oral clonidine (100 μg) has enhanced the onset and prolonged the duration of spinal analgesia, provided sedation with no respiratory depression. The hemodynamic parameters remained stabilized during the pneumoperitoneum.

Clinical effects of intrathecal fentanyl on shoulder tip pain in laparoscopic total extraperitoneal inguinal hernia repair under spinal anaesthesia: a double-blind, prospective, randomized controlled trial

OBJECTIVE

The study evaluated the clinical intraoperative effects of intrathecal administration of fentanyl on shoulder tip pain in patients undergoing laparoscopic total extraperitoneal inguinal hernia repair (TEP) under spinal anaesthesia.

METHODS

Patients undergoing TEP were allocated in a double-blinded, prospective, randomized manner to two groups. Spinal anaesthesia was induced by intrathecal administration of 2.8 ml of 0.5% hyperbaric bupivacaine (14 mg) in the control group and with 2.6 ml of 0.5% hyperbaric bupivacaine (13 mg) and 10 µg fentanyl (0.2 ml) in the experimental group.

RESULTS

The quality of muscle relaxation, adequacy of operative space and incidence of pneumoperitoneum were similar in the two groups (n = 36 per group). Compared with the control group, the experimental group had significantly fewer cases of hypotension (12 [33.3%]) versus 23 [63.9%]) and shoulder tip pain (nine [25%] versus 18 [50%]). Intraoperative shoulder tip pain was more severe in the control group than in the experimental group.

CONCLUSIONS

Addition of intrathecal fentanyl to local anaesthetic can relieve shoulder tip pain with no change in complications, especially hypotension, during TEP under spinal anaesthesia.

Laparoscopic surgery for inguinal hernia: Current status and controversies

Repair of inguinal hernia is one of the commonest operations performed by surgeons around the world. The treatment of this common problem has seen an evolution from the pure tissue repairs to the prosthetic repairs and in the recent past to laparoscopic repair. The fact that so many hernia repairs are practiced is a testimony to the fact that probably none is distinctly superior to the other. This review assesses the current status of surgery for repair of inguinal hernia and examines the various controversial issues surrounding the subject.

Efficacy of thoracic epidural anesthesia for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is performed to minimize the postoperative morbidity and early return to work. This study was planned to evaluate the efficacy and feasibility of thoracic epidural anesthesia for laparoscopic cholecystectomy, so that it can be later used as anesthetic technique in patients when general anesthesia is not feasible.

MATERIALS AND METHODS

Forty-eight adult consented patients of ASA grade I and II of either sex scheduled for elective laparoscopic cholecystectomy were enrolled for thoracic epidural anesthesia with 15 ml of 0.75% ropivacaine and 50 μg fentanyl. Intraoperative hemodynamic parameters and respiratory efficiency were recorded. Intra-operatively patient anxiety, pain, vomiting, hypotension or any other adverse event was managed with appropriate drug regime. Postoperative pain management with epidural analgesia, and bowel recovery were also recorded.

RESULTS

The thoracic epidural anesthesia was effective for laparoscopic cholecystectomy in all except in two patients where conversion to general anesthesia was required. The hemodynamic parameters and respiratory efficiency were maintained within physiological limits. Only 4 patients required treatment for hypotension with vasopressor and 15 patients experienced shoulder pain, which was effectively managed with small doses of ketamine. The midazolam was required only in 11 patients for anxiety. The mean surgical time was 56.8±51.6 min. The 24-hour postoperative epidural infusion for analgesia was effective with limited effects on bowel and bladder function. Postoperatively only 3 patients had an episode of vomiting. There was good surgeon and patient's satisfaction.

CONCLUSIONS

The thoracic epidural anesthesia with 0.75% ropivacaine and fentanyl for elective laparoscopic cholecystectomy is efficacious and has preserved ventilation and hemodynamic changes within physiological limits during pneumoperitoneum with minimal treatable side effects.

Laparoscopic total extraperitoneal repair in femoral hernia without fixation of the mesh

BACKGROUND AND OBJECTIVES

We report on laparoscopic total extraperitoneal repair without fixation of mesh for femoral hernia in 6 patients.

METHODS

During a 3-year period, laparoscopic total extraperitoneal repair of femoral hernia was performed without mesh fixation in 6 patients. The recurrence rate, pain scores, hospital stay, and other morbidity parameters were noted. Pain scores were 1=no pain, 2=mild pain, 3=moderate pain, 4=severe pain, and 5=intolerable pain.

RESULTS

All 6 patients were females and had unilateral hernias. Mean age was 33.8+/-18.6 years, and follow-up ranged from 12 months to 36 months. Four patients were operated on while under spinal anesthesia, and 2 patients were operated on while under general anesthesia. Mean operating time was 29.2+/-10.7 minutes. The mean pain scores 24 hours and the first week after operation were, respectively, 2.33+/-0.52 and 1.33+/-0.52. Mean hospital stay was 1.17+/-0.41 days, and mean days to resumption of normal activities were 8.5+/-2.1 days. No patient had urinary retention or seroma formation in the postoperative period. At follow-up, no hernia had recurred.

CONCLUSIONS

Laparoscopic femoral hernia repair without fixing the mesh is safe, feasible, and associated with minimal morbidity and recurrence rates.

Laparoscopic total extraperitoneal inguinal hernia repair under spinal anesthesia: a study of 480 patients

OBJECTIVES

Laparoscopic total extraperitoneal inguinal hernia repair (TEP) is conventionally performed under general anesthesia (GA), and regional anesthesia is usually preferred in patients where GA is contraindicated. In this paper, we present our experience of over 8 years of using spinal anesthesia (SA) as the first choice with the contention that it is a better alternative to GA.

METHODS

SA was used in 480 patients over the last 8 years, and 464 patients underwent unilateral TEP. Strangulated and obstructed hernia patients were excluded, but irreducible hernia patients were included. Sedation was given if required, and the conversion to GA was done in patients not responding to sedation or with failure of SA. Comparative control included TEP performed under GA in our initial 49 patients.

RESULTS

Three (0.63%) patients required a conversion to GA. Hypotension requiring support was recorded in 75 (15.63%) patients. Postoperatively, 2.08% (10) patients had vomiting, as compared to 30.61% (15 patients) in patients administered GA. In all, 35.83% (172) of patients required injectable diclofenac for their abdominal pain within 2 hours postoperatively, and oral analgesic was required in 301 (62.71%) patients within the first 24 hours, while 89.80% (44) patients operated an under GA required injectable analgesics in the immediate postoperative period and subsequent oral analgesia request was the same as in patients with SA. Postural headache, persisting for an average of 2.6 days, was seen in 25 (5.21%) patients postoperatively. Average time to discharge was 2.3 days. Kernofsky's performance status showed a 98.6% satisfaction level in patients.

CONCLUSIONS

TEP done under SA has a number of advantages over GA and should be used routinely.

Laparoscopic inguinal total extraperitoneal hernia repair under spinal anesthesia without mesh fixation in 1,220 hernia repairs

BACKGROUND

The need for general anesthesia and the cost and pain due to metal staples required for fixing the mesh are the major reported disadvantages of laparoscopic total extraperitoneal (TEP) hernia repair. We studied the feasibility and results of TEP done under spinal anesthesia with non-fixation of the mesh (SA-NF). This group was compared to TEP done under general anesthesia with non-fixation of the mesh (GA-NF) and repairs done under SA with fixation of the mesh (SA-F).

METHODS

A retrospective analysis was carried out in 675 patients (1,289 hernias) in whom TEP was performed. The recurrence rate, pain scores at 24 h and 1 week, hospital stay, days to resume normal activities, seroma formation, and urinary retention rates were noted.

RESULTS

A total of 1,289 TEP repairs (675 patients) were analyzed, with 636 patients (1,220 hernias) in the SA-NF group, 16 patients (27 hernias) in the GA-NF group, and 23 patients (42 hernias) in the SA-F group. Follow up ranged from 13 to 45 months. The recurrence rates, conversion rates, and complications were similar in all three groups. The mean hospital stay, days to resume normal activities, and pain scores were significantly higher in the mesh fixation (SA-F) group.

CONCLUSIONS

TEP, done under SA and without fixation of the mesh, is safe, feasible, and associated with low recurrence rates. Since this procedure does not have the disadvantages usually attributed to TEP, it can be possibly recommended as a first-line procedure, even for unilateral inguinal hernias. Further studies are needed to substantiate this.

Experience of laparoscopic hernia repair in a laparoscopically oriented unit of a large community hospital

We describe a consecutive series of 258 laparoscopic inguinal hernia repairs in 189 patients from January 1997 to December 2004. Early results, complications, and follow-up were collected prospectively. Patients were followed in the outpatient clinic and contacted by phone at the time of this review. Three trocars were employed. The polypropylene mesh was inserted through the periumbilical trocar and fixed in the properitoneal space using titanium clips. There were no conversions and the mean operative time was 88 minutes (including bilateral cases). We had no major intraoperative accidents, and only 12 minor postoperative complications (4 urinary retentions, 6 seromas, and 2 cases of prolonged pain). Walking, hospital discharge, and return to activities were prompt, with a mean hospital stay of 1.7 days, and an average time of absence from work of 16 days. There have been 11 (4%) documented recurrences during long-term follow-up (mean, 62 months). The technique appears safe and efficacious even in a community hospital with a large laparoscopic experience.

Treating recurrence after a totally extraperitoneal approach

BACKGROUND

One of today's most highly regarded procedures for treating inguinal hernia is the totally extraperitoneal approach (TEP), but it can on occasion lead to recurrence. This is commonly managed with an open repair, a transabdominal preperitoneal procedure (TAPP), or another TEP. We report here on our years of experience with the latter.

METHODS

The endeavor to a secondary TEP is much the same as to a primary one, but certain differences are encountered as the operation proceeds. For example, many anatomical landmarks found in a first TEP cannot be seen in a second. There can also be a diminished amount of working space, and this occasionally leads to an open conversion.

RESULTS

From September 1991 to September 2005, we repaired 1,526 hernias in 1,156 male patients, using the TEP in every case. Of these, 21 were TEPs after a previous TEP. In 3 cases, the space could not be opened, and they were converted to the open Lichtenstein. One patient had peritoneal tears that led to conversion and another had conversion because of excessive bleeding. There were no complications, no bladder or bowel injuries, no transfusions, no preperitoneal hematomas, and no fatalities. All patients were discharged the same day.

CONCLUSIONS

A secondary TEP, open repair, and TAPP are alternative solutions to the problem of recurrence after TEP. However, any TEP involves a very prolonged learning curve for general surgeons, since they must learn the anatomy as well as the procedure, both at the same time. This is doubly true for the TEP after a previous TEP.