A Prospective Randomized Controlled Trial Comparing Quality of Life Following Endoscopic Totally Extraperitoneal (TEP) Versus Open Stoppa Inguinal Hernioplasty

Inguinal hernia – epidemiology, risk factors, treatment methods (literature review)

Inguinal hernias (IH) are widespread in the human population and occur in 27–43 % of men and 3–6 % of women. Many risk factors for IH have been overestimated in the last decade: male gender is considered the leading factor (the ratio between men and women is approximately 1:7), less significant factors are heredity (most significant for women), physical activity (more significant for men), age (peak prevalence of IH occurs at 5 years and 70–80 years), congenital or acquired connective tissue dysplasia, history of prostatectomy, low body mass index.Hernioplasty with the use of synthetic mesh prostheses remains the most popular technique for surgical correction of IH. Performing non-prosthetic hernioplasty is only recommended if mesh prostheses are not available, for example in poor countries. In open hernioplasty using mesh prostheses, different methods are used today: Plug & Patch, Prolene Hernia System, Parietene Progrip, sutureless plastic according to Trabucco, Stoppa, preperitoneal techniques TIPP (trans-inguinal pre-peritoneal), TREPP (transrectus pre-peritoneal), TEP (total extraperitoneal), however, none of them showed significant advantages over the gold standard of open hernioplasty – tensionfree repair according to Liechtenstein.Laparoscopic IH correction is represented by the TAPP (transabdominal preperitoneal) technique, performed through the abdominal cavity, and TEP (total extraperitoneal) – extraperitoneal prosthetic hernioplasty. None of them has a significant advantage in the treatment of IH; therefore, when choosing a treatment method, the surgeon should be guided by the cost of the operation and the level of proficiency in one or another hernioplasty technique.

A prospective randomised control trial to compare the perioperative outcomes and ergonomic challenges between triangular versus midline port placement in total extra-peritoneal repair of uncomplicated unilateral inguinal hernia

BACKGROUND

Routine TEP technique requires three skin incisions for placement of three trocars in the midline. Otherwise, this can be done by three-port triangular technique or two-hand technique. This study reports a randomised trial of perioperative outcomes and ergonomics characteristics of this procedure using two different techniques of port insertion.

METHODS

N = 28 patients were randomised into two groups for triangular three-port (TTEP) versus midline three-port TEP (MTEP) hernioplasty after informed written consent in Department of Surgery, King George's Medical University UP between September 2016 and September 2017 after institutional ethical approval. Patient-related outcomes in terms of quality of life (QOL) and ergonomic evaluation of the technique were compared in double-blinded fashion.

RESULTS

Postoperative pain score at 24 h post surgery (5.1 ± 0.6; 95% CI 4.9-5.3 vs. 4.8 ± 0.4; 95% CI 4.6-4.9) differed, while hospital stay, time to return to routine work, tolerance to oral feeds and intraoperative complications occurrence (OR 2.1; 95% CI 0.2-24.3) were comparable in both groups. Time to return to office work (5.5 ± 0.5; 95% CI 5.4-5.7 vs. 4.0 ± 0.8; 95% CI 3.7-4.3) and immediate postoperative sensation of mesh and pain score were significantly higher in MTEP compared to TTEP. Ergonomic parameters including visualization of landmark score, spreading of mesh score and total surgeon satisfaction score (TTEP 8.4 ± 0.7; 95% CI 8.1-8.6 vs. MTEP 7.0 ± 0.8; 95% CI 6.7-7.3), mental effort quotient (SMEQ score: TTEP 50.6 ± 12.7; 95% CI 45.9-55.3 vs. MTEP 70.8 ± 12.6: 95% CI 66.1-75.4) and physical effort quotient (LEDQ scores in wrist, hand, arm and shoulders) were also superior in triangular technique of port placement.

CONCLUSION

Triangular three-port TEP hernioplasty is ergonomically feasible and enables a surgeon to perform surgery safely using basic principles of laparoscopy.

Meta-analysis of patient-reported outcomes after laparoscopic versus open inguinal hernia repair

BACKGROUND

Inguinal hernia repair is a common low-risk intervention. Patient-reported outcomes (PROs) are being used increasingly as primary outcomes in clinical trials. The aim of this study was to review and meta-analyse the PROs in RCTs comparing laparoscopic versus open inguinal hernia repair techniques in adult patients.

METHODS

A systematic review and meta-analysis was carried out in accordance with PRISMA guidelines. Only RCTs in peer-reviewed journals were considered. PubMed, Ovid Embase, Scopus and the Cochrane Library were searched. In addition, four trial registries were searched. The search interval was between 1 January 1998 and 1 May 2018. Identified publications were reviewed independently by two authors. The review was registered in the PROSPERO database (CRD42018099552). Bias was assessed using the Cochrane Collaboration risk-of-bias tool.

RESULTS

Some 7192 records were identified, from which 58 unique RCTs were selected. Laparoscopic hernia repair was associated with significantly less postoperative pain in three intervals: from 2 weeks to within 6 months after surgery (risk ratio (RR) 0·74, 95 per cent c.i. 0·62 to 0·88), 6 months to 1 year (RR 0·74, 0·59 to 0·93) and 1 year onwards (RR 0·62, 0·47 to 0·82). Paraesthesia (RR 0·27, 0·18 to 0·40) and patient-reported satisfaction (RR 0·91, 0·85 to 0·98) were also significantly better in the laparoscopic repair group.

CONCLUSION

The data and analysis reported in this study reflect the most up-to-date evidence available for the surgeon to counsel patients. It was constrained by heterogeneity of reporting for several outcomes.