1
|
Zwols TLR, van der Bilt ARM, Veeger NJGM, Möllers MJW, Hess DA, Brandsma HT, Jutte E, Veldman PHJM, Eker HH, Koning GG, Pierie JPEN. Learning and implementation of TransREctus sheath PrePeritoneal procedure for inguinal hernia repair. Hernia 2024; 28:1309-1315. [PMID: 38760626 PMCID: PMC11297057 DOI: 10.1007/s10029-024-03031-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/17/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE The TransREctus sheath PrePeritoneal procedure (TREPP) was introduced as an alternative open and preperitoneal technique for inguinal hernia mesh repair, demonstrating safety and efficacy in retro- and prospective studies. However, little is known about the technique's inherent learning curve. In this study, we aimed to determine TREPP learning curve effects after its implementation in high-volume surgical practice. METHODS All primary, unilateral TREPP procedures performed in the first three years after implementation (between January 2016 and December 2018) were included out of a large preconstructed regional inguinal hernia database. Data were analyzed on outcome (i.e., surgical complications, hernia recurrences, postoperative pain). Learning curve effects were analyzed by assessing outcome in relation to surgeon experience. RESULTS In total, 422 primary, unilateral TREPP procedures were performed in 419 patients. In three patients a unilateral TREPP procedure was performed on both sides separated in time. A total of 99 surgical complications were registered in 83 procedures (19.6% of all procedures), most commonly inguinal postoperative pain (8%) and bleeding complications (7%). Hernia recurrences were observed in 17 patients (4%). No statistically significant differences on outcome were found between different surgeon experience (< 40 procedures, 40-80 procedures, > 80 procedures). CONCLUSION Implementation of TREPP seems not to be associated with a notable increase of adverse events. We were not able to detect a clear learning curve limit, potentially suggesting a relatively short learning curve among already experienced hernia surgeons compared to other guideline techniques.
Collapse
Affiliation(s)
- T L R Zwols
- Postgraduate School of Medicine, University Medical Centre Groningen, Groningen, The Netherlands.
| | | | - N J G M Veeger
- MCL Academy, Medical Center Leeuwarden, Leeuwarden, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M J W Möllers
- Department of Surgery, Nij Smellinghe Hospital, Drachten, The Netherlands
| | - D A Hess
- Department of Surgery, Antonius Hospital, Sneek, The Netherlands
| | - H T Brandsma
- Department of Surgery, Antonius Hospital, Sneek, The Netherlands
| | - E Jutte
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - P H J M Veldman
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - H H Eker
- Department of Surgery, University Hospital, Ghent, Belgium
| | - G G Koning
- Department of Surgery, Euregio Hospital, Nordhorn, Germany
| | - J P E N Pierie
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
- Postgraduate School of Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| |
Collapse
|
2
|
Faessen JL, Stoot JHMB, Broos PPHL, Vijgen GHEJ, Reisinger KW, Bouvy ND, van Vugt R. Trans rectus sheath extra-peritoneal procedure (TREPP) for inguinal hernia repair under local anesthesia with sedation in the outpatient clinic: a feasibility study. Langenbecks Arch Surg 2024; 409:188. [PMID: 38896330 DOI: 10.1007/s00423-024-03383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/15/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND The Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) is an open procedure in which the mesh is placed in the preperitoneal space and is therefore associated with less chronic post-operative inguinal pain. TREPP is primarily performed under general or spinal anesthesia, however, it is also possible to perform under sedation and local anesthesia with potentially advantages. This retrospective feasibility pilot study investigates the safety and efficiency of TREPP under local anesthesia in the outpatient clinic in comparison with Lichtenstein. METHODS Between 2019 and 2022, all patients who underwent an elective inguinal hernia repair under local anesthesia in the outpatient clinic operation theatre were assessed. 34 patients in the TREPP group and 213 patients in the Lichtenstein group were included. Outcomes were complications, operating time, theatre time, and early inguinal hernia recurrence within 8 weeks and 6 months post-operatively. RESULTS No significant differences in complications such as wound infection, hematoma, seroma, urine retention and early recurrence between TREPP and Lichtenstein were found. Post-operative pain at 8 weeks was not significantly higher after Lichtenstein (8.8% vs. 18.8%, P = 0.22). Operating time (21.0 (IQR: 16.0-27.3) minutes vs. 39.0 (IQR: 31.5-45.0) minutes, P < 0.001) and theatre time (37.5 (IQR: 30.8-42.5) minutes vs. 54.0 (IQR: 46.0-62.0) minutes, P < 0.001) was significantly shorter for TREPP. CONCLUSION This pilot study showed that TREPP appears to be feasible to perform safely under local anesthesia with comparable complication rates and substantially shorter operation time than Lichtenstein. These results justify further research with a larger study population and a longer period of follow up in order to provide firm conclusions.
Collapse
Affiliation(s)
- J L Faessen
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands.
| | - J H M B Stoot
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands
| | - P P H L Broos
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands
| | - G H E J Vijgen
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | - K W Reisinger
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands
| | - N D Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R van Vugt
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands
| |
Collapse
|
3
|
Silveira CAB, Poli de Figueiredo SM, Dias YJM, Martin RRH, Rasador ACD, Fernandez MG, Lu R. Transinguinal preperitoneal (TIPP) versus Lichtenstein for inguinal hernia repair: a systematic review and meta-analysis. Hernia 2023; 27:1375-1385. [PMID: 37715825 DOI: 10.1007/s10029-023-02882-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/03/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE We aimed to perform a systematic review and meta-analysis comparing postoperative outcomes in inguinal hernia repair with TIPP versus Lichtenstein technique. METHODS Cochrane Central, Scopus, and PubMed were systematically searched for studies comparing TIPP and Lichtenstein´s technique for inguinal hernia repair. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, the Visual Analogue Pain Score, chronic pain, paresthesia rates, and recurrence. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics and random-risk effect was used if I2 > 25%. RESULTS 790 studies were screened and 44 were thoroughly reviewed. A total of nine studies, comprising 8428 patients were included, of whom 4185 (49.7%) received TIPP and 4243 (50.3%) received Lichtenstein. We found that TIPP presented less chronic pain (OR 0.43; 95% CI 0.20-0.93 P = 0.03; I2 = 84%) and paresthesia rates (OR 0.27; 95% CI 0.07-0.99; P = 0.05; I2 = 63%) than Lichtenstein group. In addition, TIPP was associated with a lower VAS pain score at 14 postoperative day (MD - 0.93; 95% CI - 1.48 to - 0.39; P = 0.0007; I2 = 99%). The data showed a lower operative time with the TIPP technique (MD - 7.18; 95% CI - 12.50, - 1.87; P = 0.008; I2 = 94%). We found no statistical difference between groups regarding the other outcomes analyzed. CONCLUSION TIPP may be a valuable technique for inguinal hernias. It was associated with lower chronic pain, and paresthesia when compared to Lichtenstein technique. Further long-term randomized studies are necessary to confirm our findings. Study registration A review protocol for this meta-analysis was registered at PROSPERO (CRD42023434909).
Collapse
Affiliation(s)
- C A B Silveira
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil.
| | | | - Y J M Dias
- Washington University in St. Louis, St. Louis, MO, USA
| | - R R H Martin
- Endocrine Surgery Department, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A C D Rasador
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - M G Fernandez
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - R Lu
- University of Texas Medical Branch, Galveston, TX, USA
| |
Collapse
|
4
|
Sams E, Stephenson BM. Delivering what inguinal hernia patients really really want. Hernia 2023; 27:1617. [PMID: 37902890 DOI: 10.1007/s10029-023-02899-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/18/2023] [Indexed: 11/01/2023]
Affiliation(s)
- E Sams
- Department of Surgery, St Joseph's Private Hospital, Newport, South Wales, UK
| | - Brian M Stephenson
- Department of Surgery, St Joseph's Private Hospital, Newport, South Wales, UK.
| |
Collapse
|
5
|
Sinha R, Yadav AS, Sharma Y, Chanda S, Sharma OK, Srivastava N. Modified Open Anterior Preperitoneal Repair. JSLS 2023; 27:e2023.00044. [PMID: 38045818 PMCID: PMC10690483 DOI: 10.4293/jsls.2023.00044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Background and Objectives Modified anterior preperitoneal (mAPP) repair for inguinal hernia (IH) was compared with Lichtenstein repair (LR) and laparoscopic transabdominal preperitoneal (TAPP) repairs. Methods IH patients, after exclusions and subsequent matching for age, type, and extent of hernia, were assigned randomly for mAPP, LR or TAPP repair. The same surgical team performed all operations. Data of predefined endpoints for all the three groups were statistically compared. Results One hundred thirty-five patients underwent mAPP, 91 patients LR, and 181 patients TAPP. The operating time for both unilateral and bilateral hernias in the mAPP group was significantly shorter than in LR and TAPP groups. mAPP patients were discharged in significantly less time than LR patients but later than TAPP patients. Postoperative visual analog scale (VAS) score at 24 hours in the mAPP patients was significantly less than LR but at 48 hours the difference was equivocal. But VAS score after mAPP at 24 and 48 hrs was more than in TAPP patients. However, the pain score across all the three groups was similar at 7 days. There was no surgical site infection (SSI) or mesh infection in any patient. Chronic postoperative inguinal pain was seen less often after mAPP than after LR but was least in TAPP patients. Recurrence across all the three groups was not much different. Conclusion mAPP appears to be a better choice for open IH repair than LR and matches the advantages of Laparoscopic repairs.
Collapse
Affiliation(s)
- Rajeev Sinha
- Department of Surgery, Maharani Laxmi Bai Medical College, Jhansi, India (all authors)
| | - Albail S Yadav
- Department of Surgery, Maharani Laxmi Bai Medical College, Jhansi, India (all authors)
| | - Yasharth Sharma
- Department of Surgery, Maharani Laxmi Bai Medical College, Jhansi, India (all authors)
| | - Swarnava Chanda
- Department of Surgery, Maharani Laxmi Bai Medical College, Jhansi, India (all authors)
| | - Om Kumar Sharma
- Department of Surgery, Maharani Laxmi Bai Medical College, Jhansi, India (all authors)
| | - Nalin Srivastava
- Department of Surgery, Maharani Laxmi Bai Medical College, Jhansi, India (all authors)
| |
Collapse
|
6
|
Posterior mesh inguinal hernia repairs: a propensity score matched analysis of laparoscopic and robotic versus open approaches. Hernia 2023; 27:93-104. [PMID: 36125632 PMCID: PMC9931785 DOI: 10.1007/s10029-022-02680-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/04/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE International guidelines suggest the use of lapro-endoscopic technique for primary unilateral inguinal hernia (IHR) because of lower postoperative pain and reduction in chronic pain. It is unclear if the primary benefit is due to the minimally invasive approach, the posterior mesh position or both. Further research evaluating posterior mesh placement using open preperitoneal techniques is recommended. A potential benefit of open preperitoneal repair is the avoidance of general anesthesia, as these repairs can be performed under local anesthesia. This study compares clinical and patient-reported outcomes after unilateral laparo-endoscopic, robotic, and open posterior mesh IHRs. METHODS We performed a propensity score matched analysis of patients undergoing IHR between 2012 and 2021 in the Abdominal Core Health Quality Collaborative registry. 10,409 patients underwent a unilateral IHR via a posterior approach. Hernia repairs were performed via minimally invasive surgery (MIS) which includes laparoscopic and robotic transabdominal preperitoneal (TAPP), laparoscopic totally extraperitoneal (TEP), or open transrectus preperitoneal/open preperitoneal (TREPP/OPP) approaches. Propensity score matching (PSM) utilizing nearest neighbor matching accounted for differences in baseline characteristics and possible confounding variables between groups. We matched 816 patients in the MIS cohort with 816 patients in the TREPP/OPP group. Outcomes included patient reported quality of life, hernia recurrence, and postoperative opioid use. RESULTS Improvement was seen after TREPP/OPP as compared to MIS IHR in EuraHS at 30 days (Median(IQR) 7.0 (2.0-16.64) vs 10 (2.0-24.0); OR 0.69 [0.55-0.85]; p = 0.001) and 6 months (1.0 (0.0-4.0) vs 2.0 (0.0-4.0); OR 0.63 [0.46-85]; p = 0.002), patient-reported opioid use at 30-day follow-up (18% vs 45% OR 0.26 [0.19-0.35]; p < 0.001), and rates of surgical site occurrences (0.8% vs 4.9% OR 0.16 [0.06-0.35]; p < 0.001). There were no differences in EuraHS scores and recurrences at 1 year. CONCLUSIONS This study demonstrates a potential benefit of open posterior mesh placement over MIS repair in short-term quality of life and seroma formation with equivalent rates of hernia recurrence. Further study is needed to better understand these differences and determine the reproducibility of these findings outside of high-volume specialty centers.
Collapse
|
7
|
Meta-analysis of the outcomes of Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) for inguinal hernia. Hernia 2022; 26:989-997. [PMID: 35006472 DOI: 10.1007/s10029-021-02554-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/08/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To evaluate the outcomes of Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) in patients undergoing elective inguinal hernia repair. METHODS In compliance with PRISMA statement standards, electronic databases were searched to identify all studies reporting the outcomes of TREPP in patients undergoing elective inguinal hernia repair. The outcomes of interest included recurrence, chronic pain, haematoma, and wound infection. Proportion meta-analysis model was constructed to quantify the risk of postoperative complications and direct comparison meta-analysis model was constructed to compare the outcomes of TREPP and other open techniques. Random-effects modelling was applied to calculate pooled outcome data. RESULTS Seven studies enrolling 1891 patients undergoing TREPP were included. The mean operative time was 26 min (95% CI 15-36). Pooled analyses showed that TREPP was associated with 3.00% (95% CI 1.00-6.00%) risk of recurrence, 3.00% (95% CI 2.00-6.00%) risk of chronic pain, 8.00% (95% CI 0.00-20.00%) risk of haematoma, and 3.00% (95% CI 0.00-6.00%) risk of wound infection. The results remained consistent through subgroup analysis of patients with primary hernias and those with recurrent hernias. Analysis of a limited number of comparative studies showed no difference between TREPP and Lichtenstein technique in terms of recurrence (OR 1.57, P = 0.26) and chronic pain (OR 1.16, P = 0.59). CONCLUSIONS The best available evidence suggests that TREPP may be a promising technique for elective repair of inguinal hernias as indicated by low risks of recurrence, chronic pain, haematoma, and wound infection. The available evidence is limited to studies from a same country conducted by almost the same research group which may affect generalisability of the findings. Moreover, there is a lack of comparative evidence on outcomes of TREPP versus other techniques highlighting a need for high-quality randomised controlled trials for definite conclusions. Although the available evidence is not adequate for definite conclusions, the results of current study can be used for sample size calculation and power analysis in future trials.
Collapse
|