Extraperitoneal Inguinal Hernia Repair Research Articles

V-028 USE OF ARTICULATED INSTRUMENTS IN EXTRAPERITONEAL ABDOMINAL WALL SURGERY

Abstract Introduction One of the limitations in extraperitoneal abdominal wall surgery is the reduced range of movements of conventional instruments. The aim of this video was to show the advantages of articulated instruments. Case presentation The first case was a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair of a direct bilateral hernia in a male patient. In this intervention the articulated grasper assisted with the isolation of the hernia sac and allowed to modify the direction of the traction during the dissection. The second case was an extended totally extraperitoneal (eTEP) repair of a M3W2 incisional hernia associated to rectus diastasis in a female patient. The articulated instrument gave an increased traction adapted to the surface of the posterior rectus sheath and marked the limits for the section with the scissors. Conclusion The articulated instruments allowed an increased mobility in the extraperitoneal field. Note: the articulated instruments were manufactured by IMM, Mannheim, Germany.

Transurethral resection of the prostate (TURP) and laparoscopic inguinal hernioplasty as combined versus separate procedures in the Era of COVID 19

Background: This study aimed to evaluate concurrent transurethral resection of the prostate (TURP) and laparoscopic totally extraperitoneal (TEP) inguinal hernia repair with determination of outcomes as combined versus separate procedures in the era of COVID 19. Materials and Methods: This prospective randomized control study was conducted at Theodor Bilharz Research Institute hospital from 2021 to 2022. It included 52 patients with co-existing uncomplicated unilateral or bilateral primary inguinal hernia and significant benign prostatic hypertrophy were operated in the same sitting in group A while in separate sessions in group B. The following outcomes were compared: duration of the surgery, conversion to open surgery (TURP or TEP), intraoperative and post-operative complications, duration of hospital stay, recurrence, patient satisfaction and pain scores, time taken to resume normal activity and cost of the treatment. Results: This study included 52 patients with a mean age of 53 years (range of 45–80 years). The average time taken for the surgery was 126 min in group A while in group B was 140 min with no conversion to open prostatectomy or open hernia repair. The mean post-operative stay was 1.2 days in group A while in group B was 4.8 days.

Efficacy of Laparoscopic Totally Extraperitoneal Repair for Inguinal Hernia.

Objective To assess the treatment efficacy of laparoscopic totally extraperitoneal repair for inguinal hernia. Methods Between November 2018 and May 2020, 130 patients with inguinal hernias diagnosed and treated in our hospital were randomly recruited and assigned to receive either tension-free hernia repair (control group) or laparoscopic totally extraperitoneal repair (study group) at the random method. All patients received routine care including external traditional Chinese medicine (TCM) application. Outcome measures included surgical indices, numeric rating scale (NRS) scores, infections, and postoperative complications. Results Laparoscopic surgery is associated with a shorter operation duration, time-lapse before postoperative off-bed activity, and hospital stay, as well as less intraoperative hemorrhage volume compared to tension-free hernia repair in the control group. Patients in the study group had considerably lower NRS ratings after therapy than those in the control group. (P < 0.05). After treatment, the levels of blood cell count (WBC), C-reactive protein (CRP), and procalcitonin (PCT) in the study group were lower than those in the control group (P < 0.05). In the control group, there were 0 cases of hematoma, 3 cases of subcutaneous effusion, 4 cases of urinary retention, 5 cases of scrotal effusion, and 1 case of bladder injury. In the study group, there were 0 cases of hematoma, 1 case of subcutaneous fluid, 1 case of urinary retention, 0 cases of scrotal fluid, and 0 cases of bladder injury. Laparoscopic surgery resulted in a lower incidence of postoperative complications versus traditional surgery (P <0.05). Conclusion Laparoscopic totally extraperitoneal repair for inguinal hernia improves the intraoperative indices, mitigates postoperative pain, and reduces the risks of infections and complications, with the advantages of short operation duration, less hemorrhage volume, and shorter hospital stay. It shows great potential for clinical promotion.

The Laparo- Endoscopic Enhanced View Totally Extraperitoneal (e-TEP) Repair for Inguinal Hernia: Initial experience at Mahatma Gandhi Hospital, Jaipur.

The Laparo- Endoscopic Enhanced View Totally Extraperitoneal (e-TEP) Repair for Inguinal Hernia: Initial experience at Mahatma Gandhi Hospital, Jaipur.

Mesh size may not affect recurrence in laparoscopic totally extraperitoneal repair of inguinal hernias

A mesh is usually employed to cover defects when performing laparoscopic totally extraperitoneal repair (TEP) of inguinal hernias. However, there is insufficient evidence for an appropriate mesh size. Therefore, we aimed to compare the recurrence rate between large- and medium-mesh laparoscopic TEP. Patients who underwent laparoscopic TEP for primary inguinal hernias from January 2012 to March 2020 were included. We retrospectively reviewed electric medical records. The primary outcome was the difference in recurrence rate between the large and medium meshes. The large mesh was 10.3 × 15.7 cm, and the medium mesh was 7.9 × 13.4 cm or 9 × 13 cm. In total, 446 patients were included in the study. Of these patients, 177 were in the large-mesh group, and 269 were in the medium-mesh group. The average ages of the large- and medium-mesh groups were 58.4 and 56.9 years, respectively (P = .361). In both groups (large vs medium), males were dominant (93.2% vs 93.6%, P = .850), and indirect hernias (87.0% vs 88.1%, P = .740) were dominant. There was no difference in body mass index (P = .883) or hernia side (P = .770). Peritoneal tearing as an intraoperative complication occurred frequently in the large-mesh group (13.6% vs 3.3%, P < .001). During the mean follow-up period of 28 months, recurrence occurred in 3 (1.7%) and 13 (4.8%) patients in the large- and medium-mesh groups, respectively. However, there was no statistical significance (P = .262). Mesh size may not affect recurrence after laparoscopic TEP of primary inguinal hernias.

Laparoscopic total extra-peritoneal (TEP) inguinal hernia repair under local anesthesia by topical lidocaine injection.

Laparoscopic total extra-peritoneal (TEP) inguinal hernia repair is usually performed under general anesthesia (GA) for muscle relaxation. However, TEP hernia repair may be reluctant in high-risk patients of GA. The aim of this study was to compare the outcomes of the TEP under GA and local anesthesia (LA). We retrospectively analyzed patients with inguinal hernia who underwent TEP under GA or LA in a single center from December 2016 to May 2018. The outcomes, such as demographics, duration of surgery, length of hospital stay, visual analog scale (VAS), and postoperative complications, were compared in each group. Seventy-six patients with inguinal hernia underwent TEP under GA (n = 52) or LA (n = 24). Total operation time (mean ±standard deviation; GA, 111.6 ± 23.0min; LA, 76.3 ± 18.0min; p < 0.001) and length of hospital stay (GA, 38.3 ± 11.6min; LA, 30.3 ± 15.6min; p < 0.014) were shorter in LA group compared to GA group. There were no significant differences in postoperative VAS (1h, p = 0.247; 4h, p = 0.086; 12h, p = 0.469; 24h, p = 0.411), postoperative adverse effects (vomiting, p = 0.570; urinary retention, p = 0.214; headache, p = 0.494), and postoperative complications (seroma, p = 0.348; scrotal edema, p = 0.178; recurrence, p = 0.822) between LA group and GA group. Compared with GA, there were no differences in postoperative pain and complications in patients who underwent TEP hernia repair under LA. Furthermore, in LA group, total operation time and length of hospital stay were shortened.

Early Results of Comparison of Hydrophilic Anatomical Mesh and Polypropylene Mesh for Laparoscopic Total Extraperitoneal (TEP) Inguinal Hernia Repair.

To compare the results, feasibility, and effectiveness of laparoscopic total extraperitoneal (TEP) hernia repair made using anatomical hydrophilic mesh and polypropylene mesh. Descriptive study. Department of General Surgery, Recepc Tayyip Erdoğan University Training and Research Hospital, Rize, Turkey and Department of General Surgery, Ondokuz Mayıs University Medical Faculty, Samsun, Turkey from January 2017 to October 2020. Comparative analysis on patient who had TEP for inguinal hernia. Group 1 included repairs using hydrophilic anatomical mesh, Group 2 included repairs using polypropylene mesh. Both were compared for operation times, complications, and return to work. There were 34 patients in Group 1 and 31 patients in Group 2. The average operation time was shorter in Group 1 (p = 0.001). Postoperative complications, were significantly less common in Group 1 (p = 0.045). Patients were able to return to their work-life earlier in Group 1 after surgery (p = 0.001). Both anatomic mesh and polypropylene mesh can be used in TEP hernia repair. These two materials stand out with their different properties. Whereas anatomical mesh shortens the operation time, decreases the rate of postoperative complications, and enables the early return to work, polypropylene mesh is cost-effective and easily accessible. Inguinal hernia, Postoperative complication, Laparoscopic total extraperitoneal (TEP).

Surgical outcomes of laparoscopic total extraperitoneal (TEP) inguinal hernia repair compared with Lichtenstein tension-free open mesh inguinal hernia repair: A prospective randomized study.

Inguinal hernia repair is one of the most frequently performed surgery. The ideal procedure for inguinal hernia repair remains controversial. Open Lichtenstein tension-free mesh repair (LMR) is one of the most preferred open techniques with satisfactory outcomes. Laparoscopic approach in inguinal hernia surgery remains controversial, especially in comparison with open procedures. In this study, we have reported a comparison of laparoscopic total extraperitoneal (TEP) inguinal hernia repair with LMR. Postoperative pain, operative time, complications like seroma, wound infection, chronic groin pain, and recurrence rate were parameters to evaluate the outcome.One hundred seventy-four patients were included in the study by consecutive randomized prospective sampling. The patients were divided into 2 groups: group A, laparoscopic TEP inguinal hernia repair, and group B, LMR. The procedures were performed by experienced surgeons. The primary outcomes were evaluated based on postoperative pain and recurrence rate. Secondary outcomes considered for evaluation were operative time, complications like seroma, infection, and chronic groin pain.Severe pain was reported in group A (7.9%) compared to group B (15.1%), which was statistically significant (P < .001). Moderate pain was reported more in group B (70.9%) compared to group A (29.5%) (P < .001). The mean operative time in group A was 84.6 ± 32.2, which was significantly higher than that in group B, 59.2 ± 14.8. There was no major complication in both groups. The chronic pain postoperatively was significantly in higher number of patients in group B vs group A (22.09% vs 3.4%). The postoperative hospital stay period was significantly lesser for group A vs for group B (2.68 ± 1.52 vs 3.86 ± 6.16). Time duration taken to resume normal activities was significantly lower in group A (13.6 ± 6.8) vs (19.8 ± 4.6) in group B (P < .001).Although there is definite evidence of longer operative time and learning curve, laparoscopic TEP has added advantages like less postoperative pain, early resumption of normal activities, less chronic groin pain, and comparable recurrence rate compared to open Lichtenstein repair. Laparoscopic TEP can be performed with acceptable outcomes and less postoperative complications if performed by experienced hands.

Quality of life of patients after inguinal hernia repair

Introduction. Endoscopic procedures for inguinal hernia repair have become widespread. There are many methods of such treatment: transinguinal preperitoneal mesh-plasty (TIPP), TAPP, TEP, MINI (combination of TEP and TAPP). However, the most common among them are TAPP and TEP. Despite the fact that these procedures are now common in many hospitals, the choice of tactics and repair procedures for different types of inguinal hernias is still uncertain. First, it concerns the quality of life of patients.&#x0D; Aim. The aim of this study was to compare TAPP, TEP and Lichtenstein based on quality of life analysis using the EuraHS-QoL scale.&#x0D; Materials and methods. We performed surgical treatment of inguinal hernia in 211 patients. Lichtenstein's procedure was performed in 65 patients (Lichtenstein group), transabdominal preperitoneal (TAPP) inguinal hernia repair in 81 patients (TAPP group) and totally extraperitoneal (TEP) inguinal hernia repair in 65 patients (TEP group). We assessed quality of life using a special scale for hernias (EuraHS-QoL). The missing values were treated according to the instructions of the validation study.&#x0D; Results and discussion. As we expected, inguinal hernia repair improved EuraHS-QoL scores in all groups. In the Lichtenstein group, the total mean decreased from 51.2 to 11.8 (4.3 times) (r=-0.13), in the TAPP group – from 51.1 to 9.9 (5.2 times), in the TEP group – from 51.2 to 12.6 (4.1 times). Cosmetic discomfort was highest at the follow-up visit in patients in the Lichtenstein group (4.2). In the TAPP group, this indicator was probably (p&lt;0.05) the smallest (3.0). Low-traumatic methods of operations in modern surgery are priorities today. The Lichtenstein procedure, despite its simplicity, is a traumatic operation compared to TAPP and TEP.&#x0D; Conclusions. Different options for inguinal hernia repair, which are based on the tension-free principle of inguinal canal correction, can be useful. However, when we analyzed the quality of life according to the EuraHS-QoL scale, we decided that transabdominal preperitoneal (TAPP) inguinal hernia repair is the most optimal in terms of various indicators.

Author response to: A randomized clinical trial comparing early patient-reported pain after open anterior mesh repair versus totally extraperitoneal repair of inguinal hernia.

Author response to: A randomized clinical trial comparing early patient-reported pain after open anterior mesh repair versus totally extraperitoneal repair of inguinal hernia.

Comment on: A randomized clinical trial comparing early patient-reported pain after open anterior mesh repair versus totally extraperitoneal repair of inguinal hernia.

Comment on: A randomized clinical trial comparing early patient-reported pain after open anterior mesh repair versus totally extraperitoneal repair of inguinal hernia.

Effects of neuromuscular blockade on the surgical conditions of laparoscopic totally extraperitoneal inguinal hernia repair: a randomized clinical trial.

Unlike other laparoscopic techniques, the peritoneum is not incised in laparoscopic totally extraperitoneal inguinal hernia repair (TEP), and the preperitoneal space is developed as the surgical field by blunt dissection and CO2 insufflation. While many studies have investigated the effect of neuromuscular blockade (NMB) on the surgical conditions and postoperative pain of laparoscopic intraperitoneal surgery, few studies have investigated those of TEP. In the present study, we investigated the effect of NMB on the surgical conditions and postoperative pain of TEP. Forty-two adult patients scheduled for unilateral TEP under general anesthesia with remifentanil and desflurane were randomly assigned to paralyzed or non-paralyzed groups. In the paralyzed group, rocuronium doses were administered to maintain post-tetanic count at ≤ 5 during surgery. Non-paralyzed subjects were not given any rocuronium. Postoperatively, surgeon-evaluated surgical conditions, assessed using a 100-mm visual analogue scale ranging from 0mm (not acceptable) to 100mm (excellent), were compared between the two groups. For evaluation of postoperative pain, the time from the end of anesthesia to the initial requirement of postoperative analgesia was compared by the log-rank test. Median [interquartile range] score of surgical condition in the paralyzed and non-paralyzed groups were 84 [75-90] and 84 [78-87], respectively (P = 0.46). Significant differences in postoperative analgesic requirements between the two groups were not confirmed (P = 0.74). NMB did not improve the surgical conditions nor reduce postoperative pain. NMB is not routinely needed for TEP just because it is a laparoscopic procedure. The trial was registered in the UMIN clinical trials registry (UMIN000029683, October 24, 2017; Principal investigator: Masafumi Fujimoto, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000033920 ) prior to patient enrolment.

Prospective, randomized clinical trial of laparoscopic totally extraperitoneal inguinal hernia repair using conventional versus custom-made (mosquito) mesh performed in Cameroon: a short-term outcomes.

Adverse economic conditions often prevent the widespread implementation of modern surgical techniques in third world countries such as in Sub-Sahara Africa. To demonstrate that a modern technique (laparoscopic totally extraperitoneal inguinal hernioplasty [TEP]) can safely be performed at significantly lower cost using inexpensive mesh material. Douala University Hospital Gynecology, Obstetrics and Pediatrics and two affiliated centers, Ayos Regional Hospital and Edéa Regional Hospital in Cameroon. Prospective randomized controlled trial (RCT) of consecutive adult patients presenting with primary inguinal hernia treated by TEP, comparing implantation of sterilized mosquito mesh (MM) with conventional polypropylene mesh (CM). Primary endpoints were peroperative, early and midterm postoperative complications and hernia recurrence at 30months. Sixty-two patients (48 males) were randomized to MM (n = 32) or CM (n = 30). Groups were similar in age distribution and occupational features. Peroperative and early outcomes differed in terms of conversion rate (2/32 MM) due to external (electrical power supply) factors and mesh removal for early obstruction (1/30 CM). No outcome differences, including no recurrences, were noted after a median follow-up of 21months. In this RCT with medium-term follow-up, TEP performed with MM appears not inferior to CM.

Totally extraperitoneal inguinal hernia repair versus Lichtenstein repair: a one-year follow-up study

The inguinal hernia has an incidence of 27 — 43 % in males. Surgical repair is the most accepted treatment to prevent the development of complications. Laparoscopic inguinal hernia repair has become popular worldwide and includes the use of a laparoscopic technique for mesh placement behind the defect. Objective — to assess whether totally extraperitoneal (TEP) inguinal hernia repair shows benefits over Lichtenstein repair in intraoperative and one‑year follow‑up postoperative outcomes for male patients with primary unilateral inguinal hernia. Materials and methods. 53 males were randomly allocated to two groups. Group 1 included 27 patients who underwent totally extraperitoneal hernia repair using self‑gripping lightweight mesh, and group 2 included 26 patients who were treated surgically with Lichtenstein repair using lightweight mesh. Results. Both groups were comparable in mean age, type of hernia, body mass index and patient’s distribution according to the European hernia society classification. TEP repair takes on average a little less time as compared to Lichtenstein repair, and this difference is not statistically significant. The mean of visual analogue scale for pain scoring in the first 24 hours after surgery as well as in the next 24 hours is statistically significantly smaller in group 1 compared to group 2. The mean time taken to return to work was 2.15 times longer in group 2 than in group 1, and the difference was statistically significant. Conclusions. Totally extraperitoneal hernia repair shows potential benefits over Lichtenstein repair for primary unilateral inguinal hernias as it causes less pain in the postoperative period and ensures early return to work.

PROSPECTIVE STUDY OF ALTERATION IN TESTICULAR PERFUSION AND VOLUME IN LAPAROSCOPIC TOTALLY EXTRAPERITONEAL HERNIA REPAIR

PURPOSE:- The objective of this study was to assess the effect of Totally extra-peritoneal inguinal hernia repair on testicular perfusion and testicular volume. METHODS: - After obtaining ethical clearance from institutional ethical committee, the present Prospective study was conducted on 48 male patients with unilateral inguinal hernia in a tertiary care hospital. RESULTS: - The study was conducted on 48 patients over a period of 2 years from august 2017 to august 2019 after meeting inclusion and exclusion criteria. Their mean age was 45.70 years (range 21-72 years). In our study comparison of preoperative and postoperative values at third and sixth month in the patients did not show any statistically signicant alteration in the variables studied like testicular volume (p-0.987) and blood ow perfusion parameters Peak systolic velocity (p-0.591); End Diastolic velocity (p-0.526); Resistance index (p-0.415). CONCLUSION: - No alteration in testicular volume and arterial ow over a six-month period was observed among patients who underwent laparoscopic extra-peritoneal surgical correction using polypropylene prosthesis for inguinal hernia

P119 THE IMPLEMENTATION OF ROBOTIC TEP AND ETEP APPROACH IN THE MODERN INGUINAL HERNIA REPAIR : A SINGLE CENTER EXPERIENCE

Abstract Aim In a robotic surgery era, the totally extraperitoneal (TEP) inguinal hernia repair is less common than the transabdominal preperitoneal (TAPP) approach. The enhanced-view TEP (eTEP) has been proposed as a modification to the standard TEP technique. The aim of this study is to present a single centre’s experience in Robotic TEP and eTEP inguinal hernia repair technique. Material and Methods This is a case-series presentation of patients with inguinal hernia that underwent robotic TEP and eTEP repair in a single institution. Patients’ characteristics were reviewed and perioperative outcomes were extracted. All patients were followed-up at the outpatient surgical unit. Intraoperative and postoperative parameters were analyzed. Results 21 patients (10% females) with a mean age of 58.5 years underwent robotic TEP (14 patients) and eTEP (7 patients) inguinal hernia repair. Eight patients were treated for bilateral hernia (total number of 29 hernias) and two were operated for recurrence. No conversion to open or TAPP repair was required. The mean operative time was 108 minutes for the bilateral hernias and 75 minutes for the unilateral cases. All patients were discharged the same day, after 3 to 5 hours postoperatively. Four of the patients used pain medication postoperatively. No major complications or recurrences were revealed during a mean postoperative follow-up time of 14 months Conclusions Robotic TEP and eTEP are safe and efficient surgical options in the treatment of inguinal hernia in experienced centres. The two techniques can result in high-quality outcomes regarding hospital stay, pain control and elimination of hernia recurrence.

A randomized clinical trial comparing early patient-reported pain after open anterior mesh repair versus totally extraperitoneal repair of inguinal hernia.

This was a prospective, multicentre, non-blinded, randomized clinical trial involving two parallel groups of patients. Adult patients with symptomatic unilateral primary inguinal hernia were included in this study. Patients were enrolled and treated in five Finnish hospitals. Eligible patients were randomized by use of a computer-based program to receiving either open anterior repair (modified Lichtenstein) with glue mesh fixation or totally extraperitoneal (TEP) repair. The primary aims were to compare 30-day patient-reported pain scores and return to work after surgery between the two groups. A total of 202 patients were randomized: 98 patients to TEP repair and 104 patients to open repair. All randomized patients received their allocated treatment. A total of 86 patients (88 per cent) in the TEP group and 94 patients (90 per cent) in the Lichtenstein group completed the 30-day follow-up. Patients experienced less early pain (P < 0.001) and used less analgesics after TEP repair, compared to those who had modified Lichtenstein repair. Two patients in the TEP group and five in the Lichtenstein group developed superficial wound infection (P = 0⋅446). Only one reoperation was performed in the Lichtenstein group due to haematoma. TEP inguinal hernia repair is associated with less early postoperative pain compared to the open glue mesh fixation technique. NCT03566433 (http://www.clinicaltrials.gov).

Endovideogernioplasty in patients with inguinal hernias: advantages and disadvantages

This study analyzed the results of treatment of patients with inguinal hernias, with an assessment of the advantages and disadvantages of endovideosurgical hernioplasty techniques. The clinical study used the data of 1317 patients with inguinal hernias. The results revealed that the totally extraperitoneal inguinal hernia repair had some advantages over laparoscopic hernioplasty, such as a shorter duration of surgery (43 15 min), mild pain on a visual analog scale, and an average bed-day after surgery. Complications were diagnosed in 16 (1.2%) patients, and most had ClavienDindo grade II complications. Relapses were detected in 7 (0.5%) cases. Thus, endoscopic hernioplasty (laparoscopic and totally extraperitoneal inguinal hernioplasty) was the preferred surgery for patients with bilateral inguinal hernia, recurrent hernia after traditional hernioplasty, and metabolic syndrome and young people of working age. The use of a modified technique of totally extraperitoneal inguinal hernioplasty with a clear understanding of the multifascial structure of the anterior abdominal wall may reduce the risks of both intraoperative and postoperative complications and increase the cost-effectiveness of treatment of patients with inguinal hernias, allowing us to obtain good results.

EP.TH.961Meta-analysis of Spinal Anaesthesia Versus General Anaesthesia During Laparoscopic Total Extraperitoneal Repair of Inguinal Hernia

Abstract Objectives To evaluate comparative outcomes of spinal anaesthesia (SA) and general anaesthesia (GA) during laparoscopic total extraperitoneal (TEP) repair of inguinal hernia. Methods We systematically searched MEDLINE; EMBASE; CINAHL; CENTRAL, and bibliographic reference lists. Post-operative 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 studies enrolling 1,518 patients (2,134 hernia) evaluating outcomes of laparoscopic TEP repair under SA (n = 1,277 patients, 1,877 hernia) or GA (n = 241 patients, 257 hernia). SA was associated with significantly lower post-operative pain assessed by VAS at 12 hours (MD: - 0.32, P &amp;lt; 0.0001) and shorter time to normal activities (MD: -0.30, P = 0.002) compared to GA. However, it significantly increased risk of urinary retention (OR:4.02, P = 0.01), hypotension (OR:3.97, P = 0.004), headache (OR:7.65, P = 0.003), and procedure time (MD: 3.82, P = 0.004) There was no significant difference in VAS at 24 hours (MD:0.06, P = 0.34), seroma (OR:1.54, P = 0.26), wound infection (OR:1.03, P = 0.94), and vomiting (OR:0.84, P = 0.66) between two groups. There was a non-significant decrease in overall morbidity in favour GA (OR:1.84, P = 0.17) which became significant following sensitivity analysis (OR:2.59, 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 anaesthetic modality in selected patients who are considered high risk for GA. Higher level of evidence is needed.

Proctored preceptorship model for learning eTEP repair for inguinal hernia for general surgery residents

Enhanced-view total extra-peritoneal (eTEP) inguinal hernia repair is a technically demanding procedure with a steep learning curve. Examine the feasibility and effectiveness of an instructor approach to teaching residents how to perform laparoscopic eTEP independently following a dedicated course of individual teaching. Prospective analysis of eTEP procedures performed by residents between March 2018 and September 2020. Six residents dispersed into three groups-Group A: two junior residents, Group B: two mid-level residents and Group C: two senior residents. All residents performed a unilateral IHR comprised of five core steps. Data reviewed for each procedure included the time of each step, total time and autonomy degree as assessment for every step: 1st degree-dependent (physical assistance), 2nd degree-partially dependent (vocal assistance) and 3rd degree-independent. Early and late procedures were divided at 50% of cases. Participants performed 44 procedures (220 steps). Late procedures presented with a significant improvement in all degrees of autonomy (1st degree p = 0.002, 2nd degree p = 0.007 and 3rd degree p < 0.0001) and in every step (Step 1 p = 0.015, Step 2 p = 0.006, Step 3 p < 0.0001, Step 4 p < 0.0001, Step 5 p = 0.002). There was no significant difference in surgery duration between early and late procedures (p = 0.32). At early procedures, junior residents needed significantly higher rates of physical intervention (1st degree) compared to the senior residents (p = 0.004). Conversely, there was no significant difference in 2nd degree of autonomy (p = 0.46), 3rd degree (p = 0.06) and surgery duration (p = 0.16). The last three procedures performed by all participants had no significant difference between the seniority groups in autonomy (1st degree p = 0.1, 2nd degree p = 0.18 and 3rd degree p = 0.1). Dedicated course with an individual instructor's approach is effective in achieving competence, autonomy and confidence in performing eTEP in a short time.