Inguinal hernia repair remains one of the most common elective general surgical procedures worldwide.1 The National Institute for Health and Clinical Excellence has recognized laparoscopic inguinal hernia repair as an appropriate alternative to open repair for over 20 years.2 There are 2 standard techniques of laparoscopic groin hernia repair, totally extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP). There have been many studies comparing TEP versus TAPP in terms of their safety and efficacy for repair of groin hernias.3–7 However, there are conflicting reports of both techniques. TAPP has been reported to have more complications such as visceral injury, longer operation time, higher incidence of cord edema and seroma formation, and higher postoperative pain.3–5 TEP has the advantage that the peritoneal cavity is not breached. A recent meta-analysis has shown that both the techniques are comparable in terms of intraoperative and postoperative outcomes.8
We have been using both the techniques of laparoscopic repair of groin hernia in our institute, a tertiary care referral center. We describe, herein, our experience of TEP repair of inguinal hernia over the last decade.
MATERIALS AND METHODS
This study is a retrospective analysis of a prospectively maintained database of all patients with groin hernia who underwent TEP repair in a single surgical unit between January 2004 and January 2018. Patients’ demographic profile and hernia characteristics (duration, side, extent, content, and reducibility) were noted in the prestructured form. A written informed consent was taken from all patients before surgery.
All the repairs were performed by 3 surgeons: M.C.M., V.K.B., and S.K. All are regular consultants in the Department of Surgery. M.C.M. has >25 years of experience and V.K.B. and S.K. have >15 years’ experience in performing laparoscopic procedures, both basic and advanced. M.C.M. has been performing laparoscopic hernia repair since 1999 and V.K.B. and S.K. since 2005.
TEP repair was performed under general anesthesia. Clinical outcomes included the operation time, intraoperative and postoperative complications, length of postoperative hospital stay, hernia recurrence, and chronic pain (defined as pain that persisted for >3 mo).9 Patients were followed up in the outpatient follow-up clinic by the attending surgeons and the unit residents during the postoperative course. The follow-up period was defined as days from the operation to the latest consultation documented in the clinical records. All patients were operated upon under general anesthesia. They were given antibiotic prophylaxis with a single intravenous dose of amoxicillin (1000 mg) and clavulanic acid (200 mg) at the time of induction of anesthesia. A Foley catheter was routinely used to decompress the urinary bladder in all patients.
Technique of TEP Repair
Patients were operated upon in the supine position with arms by the side and in the Trendelenburg position. Infraumbilical incision was made, and the rectus sheath was identified. Incision was made on the rectus sheath on either side of the midline to prevent inadvertent opening of the peritoneum in the midline. The recti were identified and the preperitoneal space was reached. A 12-mm Hassonport was inserted for a 10-mm 30-degree telescope and CO2 insufflation started. Initial preperitoneal space creation was carried out either by indigenous balloon dissection or by telescopic dissection. Blunt dissection using the 10-mm 30-degree telescope was carried out to create preperitoneal space until the pubis was felt with the telescope and the Cooper’s ligament (The Lighthouse) was identified. Two 5-mm ports were introduced: one just above the pubic symphysis in the midline, and another in the midline between the 12-mm port and the suprapubic 5-mm port. Inferior epigastric vessels, an important landmark in the dissection, were identified next. Indirect or direct hernia sac was reduced, and the entire posterior floor was dissected with satisfactory anatomic delineation of the area. In cases of large complete hernia sac, often, the sac was divided in between. The vas deferens was dissected off the testicular vessels. Triangle of doom was identified. The lateral limit of dissection was the anterior superior iliac spine. Inferiorly, the peritoneum was dissected down until the iliopsoas muscle became visible under the iliac fascia. Mesh was introduced through the telescopic port and spread to cover the entire myopectineal orifice. CO2 was released, and fascial defects were closed.
Mesh and Fixation
Three different types of mesh were used: preshaped 3DMax polypropylene mesh (large size) (Bard, size: 10.8×16 cm2; weight: 80 to 85 g/m2), flat heavyweight polypropylene mesh (size: 15×10 cm2; weight: 80 to 85 g/m2), and lightweight polypropylene mesh (Prolene soft; Ethicon, size: −15×10 cm2; weight: 28 g/m2). Type of mesh used depended on availability, choice of the operating surgeon, and affordability of the patient. Two-point fixation of the mesh with tacker was performed in patients with large hernia defect and in those with direct hernia with less abdominal muscle tone (mainly in elderly patients), and on the basis of the operating surgeon’s discretion.
Intraoperative and Postoperative Details
Intraoperative details including operative time, technique of dissection, hernia characteristics, presence of occult hernia, prophylactic hernia repair, type of mesh used, type of fixation used, and any other procedures carried out simultaneously were recorded in a prestructured form. Pain score was recorded on a Visual Analog Scale (VAS) at 1, 6, and 24 hours or at the time of discharge.
The complications like cord edema, seroma, or hematoma were recorded. Patients were followed up at 1 week, 6 weeks, 3 months, 6 months, and then yearly after discharge. Findings were recorded with regard to pain score on a VAS, presence of wound infection as per Center for Disease Control & Prevention criteria, seroma, cord edema, and ecchymosis. Those patients who did not turn up for follow-up were followed up telephonically, and, in case of any problems, the patients were asked to visit the outpatient follow-up clinic.
Mean, median, range, and frequencies were reported as descriptive statistics. The variables were compared using the χ2 test and the Student t test for qualitative and quantitative parameters, as appropriate. A P-value <0.05 was considered significant. SPSS software was used for statistical analysis.
Over a period of 14 years’ duration, TEP repair was performed in 841 patients, and a total of 1249 hernias were repaired.
Demographic Profile and Hernia Characteristics
The majority (96.9%) of patients were male individuals. The average age was 50.7 years (range 17 to 86 y). Nineteen patients were below 18 years of age, and 83 patients were older than 60 years of age. The majority of patients had primary hernias. Of the 748 patients with primary hernias, 345 patients had a unilateral hernia. Ninety-three patients (11%) presented with recurrent inguinal hernia mainly on the right side. Of 1249 hernias, the majority (61%) were of direct type (Table 1).
Telescopic dissection for initial space creation was performed in 721 patients (85.7%). In the remaining patients, balloon dissection was carried out for space creation. Among the patients of the balloon dissection group (120 patients), in 8 patients, the space creation was inadequate, and, in 11 patients, the balloon dissection was abandoned due to bleeding.
In all patients with a unilateral direct hernia, a contralateral dissection was performed to detect any occult hernias. An occult hernia was detected in 55 patients, and in 40 patients only weakness was seen. A mesh was placed in all patients undergoing a contralateral dissection. Thus, 40 patients underwent prophylactic repair of the contralateral side, even in the absence of an occult hernia.
Type of Mesh
Polypropylene mesh was used in all patients. Preshaped 3D mesh (Bard 3DMax) was used in 884 (61%) hernias repaired, and flat polypropelene mesh was used in 39% of the total 1249 TEP repairs. The mesh was not fixed in the majority of cases (59%). Two-point tacker fixation was used especially in patients with large direct hernias.
Most of the patients in the study group had reducible hernia. In those having irreducible hernia, preoperative manipulation were carried out under anesthesia to reduce hernia. Of 81 patients having massive irreducible inguinal hernia, successful TEP repair could be performed in 60 patients, and, in 15 patients, the procedure was converted to TAPP. Six patients required conversion to open repair.
A total of 81 (12.6%) patients underwent other procedures along with the TEP repair. Other laparoscopic procedures were performed in 48 patients, and 33 patients underwent combined open procedures (Table 2).
Mean operating time for repair of unilateral inguinal hernia was 54.8±14 minutes, and, for bilateral hernia repair, it was 77.9±26.2 minutes. In 51 patients, the procedure was converted to TAPP, and, in 30 patients, the procedure was converted to open mesh repair. The success rate of TEP repair in our series was 93.5%. However, overall, 97.5% hernias could be repaired laparoscopically.
During the procedure, a peritoneal breach occurred in 276 patients (32.8%), which compromised the working space due to associated pneumoperitoneum. Introduction of Veress needle in the right or left hypochondrium improved the working space. Inferior epigastric artery dropped during space creation in 36 (4.3%) patients. Fifteen (1.8%) patients developed surgical emphysema, which resolved spontaneously without any active intervention. There were a total of 81 conversions. The reasons for conversions were loss of domain/preperitoneal space due to peritoneal breach in 63 patients and the presence of large irreducible hernia in 17 patients. Of these patients, 51 (4.1%) were converted to TAPP, and 30 (2.4%) were converted to an open repair. One patient with massive irreducible hernia had inadvertent enterotomy during reduction of the hernia contents, and the procedure was converted to open surgery (Table 3).
Following surgery, the majority of patients were discharged within 24 hours. Only 5% of patients stayed for 48 hours or beyond.
The postoperative complications were comprised of urinary retention, cord edema, seroma, scrotal hematoma, ecchymosis, and port site infection. Seventeen patients developed urinary retention following catheter removal, and most of the patients were elderly. Eighty patients developed seroma in the postoperative period, and most of them resolved spontaneously, except for 15 patients, in whom seroma persisted for a long duration, who required aspiration. Six patients had ecchymosis around the scrotum and at the port sites; 2 of them were on antiplatelet therapy preoperatively. One patient had upper gastrointestinal bleed and was managed conservatively (Table 4).
Incidence of moderate to severe chronic groin pain (VAS score >3 and persisting for >3 mo after surgery as per International Association for the Study of Pain)9 was 1.4%. Most of the patients had dull aching pain over port sites, mainly over the umbilical port. Numbness was reported by 45 (5.4%) patients over the upper part of the scrotum and thigh at 1 and 3 months of follow-up. There were testicular pain and discomfort in 11 patients (1.3%) (Table 5).
The median duration of follow-up in this study was 72 months (range, 3 mo to 10 y). An overall 91.9% of patients were followed up at 3 months, with 8% lost to follow-up; 88.7% were followed up at 5 years, and 64% were followed up at 10 years. Two patients developed recurrence, 1 bilateral and 1 unilateral. Both of these patients were operated upon at the beginning of our learning curve. All 3 recurrences were dealt with open mesh repair. Two patients developed hernia on the contralateral side and were successfully managed with TAPP repair.
The first TEP inguinal hernia repair was described by McKernan and Laws.9 TEP repair for groin hernias is associated with very little postoperative pain and discomforts, short hospital stay, and allows rapid return to normal activity and work.10 It has the technical advantage of preserving the “peritoneal sanctity.” However, it has a learning curve because of the unfamiliar anatomy and space constraints.
In TEP repair, the preperitoneal space is entered directly by creating a plane between the posterior rectus sheath and peritoneum with the use of either balloon or telescopic dissection. Balloon dissection is the preferred technique by the majority of surgeons, although telescopic dissection is equally effective in space creation.11 A multicenter study has shown that balloon dissection was easier and safer.12 Telescopic dissection was the standard technique of space creation in our study. Space creation was adequate in both the techniques, albeit for a slightly higher rate of inferior epigastric vessels’ (IEVs) drop in patients undergoing balloon dissection for initial space creation.
The incidence of serious intraoperative complications is very low with both techniques of laparoscopic inguinal hernia repair.3–8 Major vascular injury is a very rare complication during laparoscopic inguinal hernia repair, with a reported incidence of <1%.13 TAPP has a slightly higher incidence of major vascular injury, which is attributable to access-related incidence (closed or open technique).3 The incidence of minor vascular injury to IEVs, corona mortis, or testicular vessels is not very well reported in the literature. A study reported a 2.75% incidence of bleeding from branches of the inferior epigastric artery and vessels on the pubic bone or testicular vessels.14 The available data suggest a slightly higher incidence of these minor vascular injuries following TEP repair, especially when balloon dissection is used for space creation.12 The most common IEV injury is dropping of the vessels.14
Studies have reported intraoperative bowel injury up to 0% to 0.06% in laparoscopic hernia repair.15 In the Cochrane database review, 2 comparative studies reported no visceral injuries, whereas 2 reported a higher rate in TAPP than in TEP.3 In patients who have previously undergone lower abdominal surgery or who have had suprapubic catheterization, injury to the bladder is the most common visceral complication of TEP (0.06% to 0.3%).15 In our experience, only 1 patient had an enterotomy during the reduction of content, and there was no major vascular injury. Drop of IEVs was seen more frequently when balloon dissection was used for space creation in our study.
TEP repair has a potential advantage over TAPP in that the peritoneal cavity is not breached. One of the common problems seen during TEP repair is accidental peritoneal breach, especially during dissection of the thin indirect sac. This leads to loss of extraperitoneal space and may even result in conversions. There are no exact data available on the incidence of this event. A few studies reported a 20% to 55% incidence of peritoneal breach during TEP repair.8,16 The rate of peritoneal breach was 32% in our study. However, in the majority of patients, we were able to complete the procedure successfully after decompression via Veress needle insertion in the right or left hypochondrium.
Pain, particularly chronic groin pain, is one of the least appreciated but most common complications of inguinal hernia repair. Laparoscopic repair has the advantage of lower pain scores and earlier return to activity when compared with open repair.17 Most of the nonrandomized studies have shown that both TEP and TAPP repairs were comparable in terms of acute pain score.18 Lepere and colleagues reported a series of 1972 inguinal hernias with 1290 TAPP repairs and 682 TEP procedures.19 Pain scores were equivalent in both the groups, and chronic pain was extremely rare (0.6% and 0.7% in TAPP and TEP groups, respectively).20 Cocks21 sequentially compared the results of 148 TAPP repairs with 313 TEP repairs and found no difference in terms of analgesic requirement. In randomized controlled trials, Krishna et al4 and Bansal et al5 reported higher pain scores with TAPP repair in the immediate postoperative period and up to 1 week of follow-up. This difference was attributed to the peritoneal incision in TAPP repair. However, pain scores following laparoscopic repair are much less compared with open repair, with VAS scores of <2 on follow-up.4,5 A recent meta-analysis has failed to show any difference between TEP and TAPP in terms of pain scores, and both have been found equal in terms of chronic groin pain (0.6% and 0.7%, respectively).8 The incidence of chronic groin pain in our study was 1.4%.
TEP and TAPP are not mutually exclusive procedures but complementary. In case of conversions, one may switch over to a TAPP repair from a TEP repair and provide advantages of minimally invasive surgery to the patient. Thill et al19 in a series of 848 TEP repairs reported a conversion rate of 1.1% to open repair. In a series of 3100 TEP repairs, Dulucq et al22 reported a conversion rate of 1.2%. The conversion rate in our series was 6.5% (4% converted to TAPP and 2.5% to open repair). The majority of these conversions occurred during the early part of our experience, and, also, most of these patients were having long-standing large irreducible hernias. Thus, the overall success rate of laparoscopic repair was >97.5% in our series.
Laparoscopic repair of the large scrotal hernia is a controversial subject, because it implies a large abdominal wall defect and great difficulty in dissecting the extensive hernia sac. There are no data evaluating the role of TEP in large scrotal hernias. Diaz’e et al23 state that large scrotal hernias can be managed with a laparoscopic intraperitoneal onlay mesh repair. As per the recent International Endohernia Society recommendations, both TAPP and TEP are possible therapeutic options in scrotal hernia.1 TAPP and TEP may be safely used in large hernias when performed by surgeons with a higher level of experience. Operative time, complication rate, and frequency of recurrences are higher in large hernia repairs than in normal hernia repairs.24 There were 81 massive irreducible inguinal hernias in our case series, and TEP could be successfully completed in >80% of them.
The litmus test for any hernia repair is the rate of recurrence. Recurrence is the most important endpoint of any hernia surgery. Recurrence after inguinal hernia repair is one of the most important measurable outcomes. Laparoscopic repair was considered to be associated with a higher recurrence rate due to the inherent learning curve. The overall recurrence rate for laparoscopic inguinal hernia repair has been reported to be as high as 25% in early studies.2,3 However, as the technique has been standardized and more experience has been gained, the recurrence rate after laparoscopic repair is similar if not better than open mesh repair.8 The Medical Research Council study has reported a recurrence rate of 1.9% following laparoscopic repair.25 The reported incidence of recurrence in TEP has been around 1% to 2% and, for TAPP, around 0% to 3%.22,26 Recent comparative studies have reported a recurrence rate of 0.5% to 0.7% for TAPP and 0.3% to 0.4% for TEP.8 Dulucq et al,22 in his series of 3100 TEP repairs, has reported a recurrence rate of 0.45%. There were only 3 recurrences in 2 patients in our study, which occurred during the initial phase.
The common postoperative complications of TEP repair include hematoma, seroma, cord edema, and wound infections. The overall postoperative morbidity in our series was low and compared favorably with other series.8
TEP repair is an excellent technique of laparoscopic inguinal hernia repair with acceptable complications after long-term follow-up.
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