Comparative Review of Outcomes of Totally Extraperitoneal (TEP) and Transabdominal Preperitoneal (TAPP) Primary Inguinal Hernia Repair

INTRODUCTION

There is an ongoing debate about the efficacy and postoperative outcomes of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) inguinal hernia repair. Our aim is to assess the surgical outcomes of each technique, focusing predominantly on postoperative components to determine if establishing a policy to advocate for a single technique is warranted.

METHOD

A literary review of randomized control trials and cohort studies to delineate recurrent concerns or points of contention was undertaken. A retrospective, comparative analysis was performed of TEP and TAPP primary inguinal hernia repairs performed by surgeons with more than five-year experience with their preferred technique over a three-year period (January 2020 to December 2022) at three separate institutions.

RESULTS

A total of 279 applicable cases were reviewed of which 38% (n=106) were performed as TEP and 62% (n=173) performed as TAPP. The demographic of the cohort was heavily skewed towards the male population as expected; however, there were no differences between each subgroup. TEP hernia repair showed a significantly improved postoperative pain score at one and 24 hours, respectively (1.67 ± 0.45, p < 0.05 and 1.97 ± 0.31, p < 0.05). No discernible difference was noted in the categories of length of hospital stay, recurrence rate, and overall patient satisfaction.

CONCLUSION

The study showed overall improved results using the TEP inguinal hernia repair technique; however, no statistically significant results were demonstrated in the long term to advocate for changes to pre-existing surgeon preferences.

Risk factors predicting acute postoperative pain immediately after minimally invasive inguinal hernia repair

Introduction

Acute postoperative pain remains one of the most common problems, even after laparoscopic or endoscopic hernia repair. Avoiding predictive factors for acute pain after surgery or prescribing additional analgesia for a patient who has risk factors that cannot be removed can be one of the options to reduce acute postoperative pain. However, there is a lack of clinical studies that evaluate the predictive factors of postoperative pain after transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) surgeries.

Aim

To identify independent risk factors predicting pain after laparoscopic and endoscopic inguinal hernia repair.

Material and methods

A prospective, randomized clinical trial was carried out by randomising patients into 2 groups (TAPP and TEP). Pre-operative and peri-operative findings were recorded. Postoperative pain was evaluated 3 h after the surgery using a visual analogue scale (VAS). Groups of patients who felt mild pain (VAS 0-2) and patients who felt average or severe pain (VAS 3-10) were compared.

Results

A total of 132 male patients were included in the study. Disease duration of more than 1 year, smoking, and TAPP surgery significantly increase the risk of moderate and strong pain 3 h after surgery. Conversely, shorter duration of symptoms and physical occupation decrease the risk of acute pain score greater than 3 according to the VAS.

Conclusions

The study shows that the duration since groin hernia appearance, smoking, physical occupation, and TAPP technique are possible predictive factors for acute postoperative pain after minimally invasive inguinal hernia repair. We suggest that for patients who have those predictors, some factors can be avoided or additional analgesia can be used.

Peritoneal defect herniation causing small bowel obstruction: a rare complication of transabdominal preperitoneal repair

Laparoscopic approaches to inguinal hernia repair are becoming increasingly more popular as they offer many advantages to open techniques including faster recovery and lower rates of wound infection. However, it is important to recognize complications associated with newer techniques which only become apparent with increased volume and experience. In this report, we describe a rare case of small bowel obstruction (SBO) secondary to peritoneal defect herniation post-transabdominal preperitoneal repair (TAPP). This is an uncommon complication that is sparsely reported in the literature but may have devastating consequences for the patient if unrecognized or mistakenly attributed to adhesional SBO. A high index of suspicion for internal herniation and a low index for reoperation are important with SBO in the early postoperative phase post-TAPP.

The learning curve of laparoscopic inguinal hernia repair: a comparison of three inexperienced surgeons

Introduction

Studies with inexperienced surgeons in terms of the learning curve for laparoscopic totally extraperitoneal (TEP) inguinal hernia repair are limited.

Aim

To compare three inexperienced surgeons in terms of the learning curve without supervision.

Material and methods

Patients’ data, which were from consecutive laparoscopic TEP hernioplasties between December 2017 and February 2020, were analysed retrospectively. The primary outcome was to compare the learning curve of three surgeons (Surgeon A, B, and C) in terms of complications, conversion, and duration of surgery. Secondary outcomes were recurrence rates.

Results

A total of 299 patients were included in the study. Conversion and intraoperative complication rates decreased after the first 60 cases (from 10% to 2.5%, p = 0.013 and from 9% to 2.5%, p = 0.027, respectively). The mean operative time reached a plateau of less than 40 min after 51–81 cases (Surgeon A 51, B 71, and C 81 cases). Ageing was a risk factor for intraoperative complications and recurrence (p < 0.001, p = 0.008, respectively), and higher body mass index (BMI) was a risk factor for conversion (p = 0.004). Age ≥ 60 years compared to age < 60 years increased intraoperative complications five-fold and recurrence six-fold (p = 0.001). On the other hand, BMI ≥ 30 kg/m² increased the possibility of conversion to open surgery nine-fold (p < 0.001). In addition, a positive correlation was found between the operative time and the BMI and VAS score (p = 0.004, p = 0.015, respectively).

Conclusions

In order to reach the plateau in the operative time during the TEP learning curve period, more than 50 cases should be experienced, whereas more than 60 cases are needed for conversion, intraoperative complications, and recurrence.

A study of the "Swiss-roll" folding method for placement of self-gripping mesh in TAPP

BACKGROUND

Using self-gripping mesh eliminates the need for additional mechanical fixation in laparoscopic groin hernia repair when surgeons plan to fix it. However, the mesh's 'self-gripping' characteristic makes it much more difficult to unfold and place. Here, the novel "Swiss-roll" placement method of folding self-gripping mesh is introduced and compared to the common folding placement method.

MATERIAL AND METHODS

The cohort of this prospective randomized controlled study included 100 patients who underwent transabdominal preperitoneal (TAPP) groin hernia repair in the Department of Hernia and Abdominal Wall Surgery of Shanghai East Hospital between January and December 2018. The patients were randomly assigned to the "Swiss-roll" folding group or the common folding group. The time required for mesh placement, total surgical duration, and the incidences of postoperative pain and complications were compared.

RESULTS

The times required for mesh placement in the "Swiss-roll" and common folding groups were 155.10 ± 48.66 and 202.80 ± 61.05 sec, respectively. The "Swiss-roll" folding method significantly shortened the time required for mesh placement (p = 0.000). There were no significant differences in total surgical duration and the incidences of postoperative pain and complications between the two groups.

CONCLUSIONS

The "Swiss-roll" folding method facilitates self-gripping mesh placement without increasing the incidence of complications and recurrences in TAPP.

Identifying the Essential Portions of the Skill Acquisition Process Using Item Response Theory

OBJECTIVE

Item response theory (IRT) was originally developed to make performance assessments more accurate. However, IRT analysis of the intraoperative performance of surgical trainees could help identify the elements that the trainees find difficult during the skill acquisition process. The aim of this study was to identify the essential portions of the skill acquisition process of a surgical procedure using the IRT.

DESIGN

The 24-item assessment checklist was used to evaluate a recorded intra-operative performance of a laparoscopic inguinal hernia repair. The scores were analyzed using IRT to calculate the difficulty and discrimination level of each item.

SETTING

Fifteen institutes.

PARTICIPANTS

Thirty surgical trainees.

RESULTS

A total of 123 assessments were analyzed. The item analysis showed the procedure specific item "traction of peritoneum (difficulty: -0.45; discrimination: 19.37)" and generic items "instrument handling (difficulty: -0.59; discrimination: 3.82)" and "flow of procedure (difficulty: 0.09; discrimination: 3.27)" to be key elements in the skill acquisition process of the procedure.

CONCLUSIONS

Key elements in the skill acquisition process of the procedure were quantitatively identified by applying the IRT analysis. This could lead to the use of IRT in designing and developing a more effective training curriculum.

Incidence of postoperative complications in transabdominal preperitoneal repair for groin hernia is influenced by poor performance status rather than by old age

AIM

The present study was designed to evaluate the safety and feasibility of transabdominal preperitoneal (TAPP) repair for very old patients with groin hernia and to identify the risk factors predicting perioperative complications.

METHODS

A total of 140 patients treated by TAPP were reviewed retrospectively. They were divided into two groups: patients ≥80 years of age (≥80 years group; n = 26) and those <80 years of age (<80 years group; n = 114). Patient characteristics and surgical outcomes were then statistically compared between the two groups.

RESULTS

Number of patients with any comorbidities was significantly higher in the ≥80 years group than in the <80 years group (96.2% vs 61.4%, P = 0.003). There were no significant differences in surgical outcomes between the two groups. In the univariate analysis of perioperative complications, poor performance status (PS) (P = 0.014), lower hemoglobin level (P = 0.038) and lower albumin level (P = 0.016) were significantly associated with the occurrence of postoperative complications, and multivariate analysis showed that only poor PS was an independent factor (PS 0-2 vs 3-4: P = 0.034, OR 5.192 [95% CI; 1.137 to 23.71]).

CONCLUSIONS

This is the first report to show that the incidence of postoperative complications in TAPP repair for groin hernia is influenced by poor PS rather than old age. TAPP can be a safe surgical procedure for very old patients with a good PS, with benefits that are equal to those in young patients.

Safety, feasibility and clinical outcome of minimally invasive inguinal hernia repair in patients with previous radical prostatectomy: A systematic review of the literature

Background:

Radical prostatectomy (RP) represents an important acquired risk factor for the development of primary inguinal hernias (IH) with an estimated incidence rates of 15.9% within the first 2 years after surgery. The prostatectomy-related preperitoneal fibrotic reaction can make the laparoendoscopic repair of the IH technically difficult, even if safety and feasibility have not been extensively evaluated yet. We conducted a systematic review of the available literature.

Methods:

A comprehensive computer literature search of PubMed and MEDLINE databases was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Terms used to search were (‘laparoscopic’ OR ‘laparoscopy’) AND (‘inguinal’ OR ‘groin’ OR ‘hernia’) AND ‘prostatectomy’.

Results:

The literature search from PubMed and MEDLINE databases revealed 156 articles. Five articles were considered eligible for the analysis, including 229 patients who underwent 277 hernia repairs. The pooled analysis indicates no statistically significant difference of post-operative complications (Risk Ratios [RR] 2.06; 95% confidence interval [CI] 0.85–4.97), conversion to open surgery (RR 3.91; 95% CI 0.85–18.04) and recurrence of hernia (RR 1.39; 95% CI 0.39–4.93) between the post-prostatectomy group and the control group. There was a statistically significant difference of minor intraoperative complications (RR 4.42; CI 1.05–18.64), due to an injury of the inferior epigastric vessels.

Conclusions:

Our systematic review suggests that, in experienced hands, safety, feasibility and clinical outcomes of minimally invasive repair of IH in patients previously treated with prostatectomy, are comparable to those patients without previous RP.

Simultaneous laparoscopic cholecystectomy and transabdominal preperitoneal hernioplasty: two case reports evaluate the safety and surgical complications

The safety of combining transabdominal preperitoneal (TAPP) hernioplasty and cholecystectomy in one laparoscopic surgery is still for many years questionable. We report two cases describing the safety and discussing the main concerns regarding the complications. As there are only few cases discuss this kind of combination, we aim to further clarify this subject to provide the best practice for our patients.

The experience and awareness of laparoendoscopic procedures among Polish surgeons in everyday clinical practice

Introduction

In 2012, a total of 56 647 inguinal hernia repairs were performed in Poland. However, the absence of a uniform hernia repair register obscures the current herniology status in Poland, especially regarding laparoendoscopic procedures.

Aim

To determine the awareness of laparoendoscopic procedures among Polish surgeons and to ascertain their everyday clinical practice.

Material and methods

The data were collected at the national hernia conference in 2016, during an interactive session for surgeons with a special interest in herniology. They could respond to the survey items using the VoxVote application. All items and response options were displayed on participants’ smartphones. The questions were related to transabdominal preperitoneal/totally extraperitoneal (TAPP/TEP) hernia repair. The surgeons responded to 27 questions regarding routine inguinal hernia repair. One hundred and six surgeons from all regions of Poland participated in the survey.

Results

19.2% of respondents never inform patients about the possibility of performing laparoendoscopic repair. 45.2% admitted that they had referred a patient with a difficult inguinal hernia to another hospital or surgeon. Seventy-five percent stated they would be willing to perform TAPP/TEP if the reimbursement rates were more favourable. In bilateral hernias, 61.6% of the respondents perform a two-step open repair, while only 25% perform a single-stage laparoendoscopic repair of bilateral hernia. In women, only 13.3% perform laparoendoscopic hernia repairs, and 19.0% do not use mesh.

Conclusions

The skill level to perform TAPP/TEP repair is still inadequate among Polish surgeons. The absence of accurate data makes it impossible to verify whether the treatment methods used are compliant with the guidelines.

Reduction of chronic post-herniotomy pain and recurrence rate. Use of the anatomical self-gripping ProGrip laparoscopic mesh in TAPP hernia repair. Preliminary results of a prospective study

Introduction

The role of fixation of the mesh is especially important in the endoscopic technique. The fixation of mesh through penetrating techniques using staples, clips or screws is associated with a significantly increased risk of developing a post-herniotomy pain syndrome.

Aim

To demonstrate the safety and efficacy of the self-fixating anatomical Parietex ProGrip laparoscopic mesh (Sofradim Production, Trévoux France) used with laparoscopic transabdominal preperitoneal hernia repair. The incidence of chronic post-herniotomy pain and recurrence rate in the follow-up after 12 months were evaluated.

Material and methods

Data analysis included all patients who underwent inguinal hernia surgery at our Surgical Department within the period from 1.05.2013 to 31.12.2014, who fulfilled the inclusion criteria. Standard surgical technique was used. Data were prospectively entered and subsequently analyzed on the Herniamed platform. Herniamed is an internet-based register in German and English language and includes all data of patients who underwent surgery for some types of hernia.

Results

There were 95 patients enrolled in the group and there were in total 156 inguinal hernias repaired. The mean follow-up was 15.52 months. At the assessment at 1 year mild discomfort in the groin was reported in 2 patients (3.51%) (1–3 VAS). No recurrence or chronic postoperative pain was reported.

Conclusions

Laparoscopic inguinal hernia repair using the transabdominal preperitoneal technique with implantation of the ProGrip laparoscopic mesh is a fast, effective and reliable method in experienced hands, which according to our results reduces the occurrence of chronic post-operative inguinal pain with simultaneously a low recurrence rate.

Single-incision trans-abdominal preperitoneal mesh hernioplasty

Single-incision laparoscopy is being used to carry out a wide variety of laparoscopic operations since its introduction in 2007. Various case reports and studies have demonstrated the safety and feasibility of single-incision laparoscopic transabdominal preperitoneal (TAPP) and totally extra-peritoneal mesh hernioplasty. However, till date, its apparent advantages have been mainly cosmetic and related to patient satisfaction. We have been performing single-incision laparoscopic TAPP mesh hernioplasty since June 2009 using conventional laparoscopic instruments. Here, we describe our technique that is aimed at standardising the method.

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.