Laparoscopic Total Extraperitoneal Hernioplasty Research Articles

Subcutaneous fat thickness predicts postoperative seroma following laparoscopic total extra-peritoneal hernioplasty.

Seroma formation is the most common cause of morbidity associated with laparoscopic inguinal hernia repair. This study aimed to examine the relationship between the thickness of subcutaneous fat (TSF) and the risk of postoperative seroma. We reviewed data from a prospective cohort of 229 male patients who underwent laparoscopic total extra-peritoneal (TEP) hernioplasty for indirect inguinal hernia between August 2018 and July 2021. The TSF was assessed using preoperative ultrasound images. The risk factors for postoperative seroma were determined using univariate and multivariate logistic regression models. Postoperative seromas occurred in 26 patients (11.4%). The factors associated with postoperative seroma included longer hernia duration, larger hernia defects, extension into the scrotum, and greater TSF (P < 0.05). In multivariate analysis, a greater TSF was independently associated with a greater risk of postoperative seroma (per 1mm: odd ratio [OR] 1.105, 95% confidence interval [CI] 1.048-1.165, P < 0.001; TSF ≥ 26.0mm: OR 7.033, 95% CI 2.485-19.901, P < 0.001). Similar results were obtained in the subgroup analysis. The area under the curve of TSF for predicting seroma formation was 0.703 (95% CI 0.601-0.806). Ultrasound-derived TSF may be a promising prognostic factor for postoperative seroma in patients undergoing laparoscopic TEP repair. Further validation is required and then this parameter can be used to improve decision-making process.

Therapeutic efficacy of programmed spatial anatomy of the myopectineal orifice in total extraperitoneal hernioplasty: a retrospective study

This study aimed to investigate the therapeutic efficacy of programmed spatial anatomy of myopectineal orifice technique in laparoscopic total extraperitoneal hernioplasty (TEP) surgery. A total of 121 adult male patients with unilateral inguinal hernias who underwent TEP in the Department of General Surgery, Wujin Hospital, affiliated with Jiangsu University, from January 2019 to December 2020 were selected. Patients were divided into the procedural (63 cases) and traditional groups (58 cases) according to the surgical methods adopted. The procedural group underwent programmed spatial anatomy of the myopectineal orifice combined with TEP, and the traditional group underwent traditional TEP. The perioperative evaluation indicators and postoperative complications were observed and compared between the two groups. Compared with the traditional group, the time of handling hernia, the intraoperative operation time, intraoperative blood loss, postoperative ambulation time, and postoperative hospital stay in the procedural group were significantly reduced (P < 0.05). The incidence of postoperative complications such as sensory nerve abnormalities and chronic pain was significantly decreased (P < 0.05), and the total incidence of complications in the procedural group was significantly lower than that in the traditional group (P < 0.05). While there was no significant difference in postoperative incision infection (P > 0.05). The programmed spatial anatomy of the myopectineal orifice can significantly improve the treatment outcome of TEP, significantly improve the patients' intraoperative and postoperative indicators, and reduce the incidence of postoperative complications. It is worthy of being promoted among young physicians and basic hospitals.

Laparoscopic Totally Extra-peritoneal Hernioplasty versus Lichtenstein Open Tension Free Mesh Repair for Inguinal Hernia

Background: Surgery for a groin hernia is the most common operation in general surgery. The recurrence rate in non-specialized centres is high, and postoperative pain and discomfort are common. The inguinal hernia repair has been a controversial area in surgical practice ever since it was associated with recurrence rates which have decreased because of the use of prosthetic mesh. Objective: This study was aimed to evaluate the benefits and harms of the total extra-peritoneal technique compared with the Lichtenstein technique for inguinal hernia repair. Patients and Material: This randomized controlled trial study included a total of 40 male patients aged between 14 and 60 years with unilateral or bilateral inguinal hernia, attending at Outpatient Clinic, Aswan University Hospital and followed up there. This study was conducted period from August 2017 to August 2018. They were randomly divided into two groups; Group A Open Lichtenstein hernioplasty and Group B; laparoscopic total extraperitoneal hernioplasty (TEP). Results: There was a statistically significant difference between Groups A and B cases as regard operative time and hospital stay. There was no statistically significant difference between Group A and B cases as regard intra-operative/postoperative complications. Also, there was no s statistically significant difference as regard VAS, recurrence in either group during the follow- up period of 6 months. Conclusions: It could be concluded that laparoscopic total extraperitoneal hernioplasty yielded better results regarding operative time and hospital stay. Yet, better results were found regarding complications, but the study could not detect statistical differences.

Does the use of monopolar energy as the preferred mode of dissection effectively reduce seroma formation in laparoscopic total extra peritoneal hernioplasty? A prospective double-blinded randomized control trial.

Seroma is a commonly encountered sequela after hernia repair. Tremendous effort has been spent to investigate the effective way to prevent this "complication" including the modification of surgical technique, use of per-peritoneal drainage, etc. There were debates about the use of monopolar diathermy versus blunt dissection in laparoscopic TEP in the prevention of seroma formation. This randomized study aims to compare the effects of using 2 techniques in laparoscopic TEP on pre-peritoneal drain output and seroma formation. From 1.9.2018 to 30.9.2019, all male and female patients presented with the first occurrence, unilateral inguinal hernia anticipated for laparoscopic TEP were enrolled into the study after informed consent. Patients were randomized into "monopolar dissection preferred" (MDP) group and "blunt dissection-preferred" (BDP) group just before commencing of operation after general anesthesia. Surgeons were instructed to use monopolar energy as main dissection method for the whole operation if possible (MDP), whereas blunt dissection is the preferred choice in BDP group, but the use of monopolar energy was allowed if needed. Total energy time was measured by a specially designed homemade device attaching to the monopolar pedals as accurate as to millisecond (ms). Pre-peritoneal drains were inserted for drainage and removed 23h after operation. Drainage output, total operating time, energy time, clinical and ultrasonic seroma sizes at day 1, day 6, 1-month post operations, recurrence are compared between 2 groups. A total of 103 patients where included. There was no significant difference in age, gender, co-morbidities, side of hernia, mean defect size, operating time, fixation adjuncts, or postoperative stay. The drain volume in BDP group is 71.13 ± 31.42mL while it in MDP group is 56.36 ± 21.46mL. The MDP group had significantly fewer drain output at 23h post operation (p = 0.007) and lower seroma incidence on days 6 (p = 0.036). Overall incidence of seroma formation was 12% on postoperative day 1, 11% on postoperative day 7. No statistically differences in postoperative pain score or complications were observed at the first week, 1- and 3-months' post operation. There was no correlation with energy time to the drain output. No recurrence was found in subsequent follow-up. Pre-peritoneal drainage is clinically safe in laparoscopic totally extra-peritoneal hernioplasty and can effectively reduce the size and incidence of seroma. The seroma formation can be further reduced by appropriate use of monopolar energy as preferred dissection approach in lap TEP. Due to limitation in measuring the actual energy time, the result should be further validated by randomized multi-centers trial on its potential benefit in hernia repair by a more accurate measuring device on energy used.

Laparoscopic totally extraperitoneal hernioplasty: Theodor Bilharz Research Institute preliminary experience

Background The two standard methods for inguinal hernioplasty is open and minimal access laparoscopic technique. Most laparoscopic surgeons use a transabdominal preperitoneal approach but totally extraperitoneal (TEP) approach potentially offers several advantages. Objective The aim in this study was to assess the learning curve, cost value, safety, and feasibility of TEP approach. Patients and methods Prospectively collected data on 185 consecutive patients submitted to laparoscopic TEP hernioplasty for inguinal hernia from 2016 to 2018 in Theodor Bilharz Research Institute Hospital. This study involved repair of primary, recurrent inguinal hernia and femoral hernia. The prolene mesh was used for groin hernia repair in all cases with and without fixation. Results All 185 cases started with the laparoscopic TEP technique with only four cases converted to transabdominal preperitoneal technique (2.1%). In 110 (60.7%) cases the mesh was placed without fixation. In 71 cases the mesh was fixed by Tackers or Histoacryl. In unilateral hernia, the mean operating time was 45 min, while in bilateral hernia it was 61 min. Intraoperative complications included three cases of inferior epigastric vessel injury which were managed by metallic clips of 5 mm. The mean pain score was 7.5, while the mean satisfaction score was 5.4. The mean hospital stay was 16.4 h. Regarding postoperative complications, 10 (5.5%) patients developed a postoperative seroma, four (2.1%) patients developed a hematoma, two (1.1%) patients developed a hydrocele, and five (2.7%) patients experienced neuropathic pain. There were three (1.1%) recurrent cases; all these cases were managed by open hernioplasty. Conclusion In this study, the laparoscopic TEP approach is found to be an effective, and safe technique regarding primary, recurrent open inguinal and femoral hernias with good learning curve to laparoscopic surgeon who started with transabdominal preperitoneal technique technique.

Dulucq's technique for laparoscopic totally extraperitoneal hernioplasty.

Background:Inguinal hernia repair has been a controversial area in surgical practice. Its complexity is reflected by the fact that numerous different procedures including both open and laparoscopic techniques are in use today. Laparoscopic totally extraperitoneal (TEP) repair is preferred over transabdominal pre-peritoneal repair as the peritoneum is not breached and also due to fewer intra-abdominal complications. This is the most elegant technique but rather difficult to perform.Aim:The purpose of this study was to describe Dulucq's technique for inguinal hernia repair and the use of three-dimensional mesh without fixation in laparoscopic TEP inguinal hernioplasty.Methods:Surgical technique of laparoscopic TEP inguinal hernia repair is detailed in the text.Results:A total of 945 hernia repairs were included in the study. The hernias were repaired by Dulucq's technique. Mean operative time was 45 min in unilateral hernia and 65 min in bilateral hernia. There were no serious complications.Conclusion:The laparoscopic TEP hernioplasty by Dulucq's technique is feasible with fewer intra-abdominal complications. The dissection must always be done with the same stages with minimal monopolar diathermy and patient in a slight Trendelenburg position.

Comparative study of polyester vs polypropylene mesh in laparoscopic inguinal hernia repair

Background: Despite of convincing advantages offered by meshes, their use in hernia surgery remains controversial due to their long-term effects. A lighter and softer mesh may decrease chronic pain and recurrence by creating less fibrosis in laparoscopic inguinal hernia repair.Methods: This study was conducted with an aim to evaluate the incidence of chronic groin pain and recurrence in polyester mesh and polypropylene mesh groups of patients in laparoscopic total extraperitoneal hernioplasty. 40 patients with simple uncomplicated inguinal hernia subjected to TEP hernioplasty using either Polyester mesh or Polypropylene mesh after being randomized into two groups over a period of one year at Department of General Surgery at SSG Hospital, Baroda. Operative data were recorded, and the patients were followed-up accordingly. Independent assessors were assigned to obtain incidence of chronic groin pain and recurrence and other secondary outcomes.Results: Chronic pain, post-operative pain scores, duration of hospital stay, early return to daily activity, and feeling of lump were significantly lower with polyester mesh as compared to Polypropylene mesh. However, there was no significant difference in both the groups with respect to recurrence and post-operative complications.Conclusions: A polyester mesh has better long-term outcomes for chronic pain, post-operative pain scores, duration of hospital stay, early return to daily activity, and feeling of lump compared with a polypropylene mesh in laparoscopic inguinal hernia repair.

Evaluation of laparoscopic total extraperitoneal hernioplasty versus open hernioplasty in the management of uncomplicated inguinal hernia

Background: Inguinal hernia repair is one of the most common operations in general surgery. Inguinal hernias are among the most common of abdominal wall hernias accounting for almost 75% with lifetime risk of 27% in men and 3% in women. Laparoscopic techniques for inguinal hernia repair, shown to be superior to open repair in terms of postoperative pain and recovery.Methods: In this study, 54 patients with inguinal swelling were taken, 27 cases each for laparoscopic TEP repair and 27 for open mesh repair were studied and results were analyzed.Results: This study shows the maximum number of patients were in the age group of 51-60years in open repair whereas 41-50years in laparoscopic TEP repair. In both the groups, right sided hernia is common. Time duration of surgery varies from 47minutes to 90minutes in open hernia repair whereas in laparoscopic repair it was 85minutes to 136.67minutes. This longer duration of surgery was attributed to learning curve. The mean duration of hospital stay was 3.26days in laparoscopic TEP repair compared to 5.85days in open repair group.Conclusions: Laparoscopic TEP repair offers a significant advantage over open mesh hernia repair. It is associated with less postoperative pain and complications, early post-operative recovery and reduced hospital stay and early resumption of normal activity and better quality of life. However, operative time was prolonged in laparoscopic TEP repair as compared to open due to the learning curve in the institution.

Preperitoneal closed-system suction drainage after totally extraperitoneal hernioplasty in the prevention of early seroma formation: a prospective double-blind randomised controlled trial.

Seroma is a virtually unavoidable early sequela after TEP hernioplasty. This randomised controlled trial evaluated the outcomes of preperitoneal closed-system suction drainage in laparoscopic totally extraperitoneal (TEP) hernioplasty for inguinal hernia. Ninety patients aged 18-80years who presented to our hospital between May 2016 and February 2017 with primary unilateral inguinal hernia were randomised into the preperitoneal drain and no-drain groups. The primary outcome was seroma size on postoperative day 6. Secondary outcomes included clinical seroma formation and seroma size on day 1, day 6, 1 and 7months postoperatively, length of postoperative stay, pain score, and recurrence. There was no significant difference in age, sex, co-morbidities, hernia side, mean hernia size, operating time, fixation adjuncts, or postoperative stay. The overall incidence of clinical seroma formation was 25.6% on postoperative day 1, 60.3% on postoperative day 6, 13.2% 1month and 0% 7months postoperatively. The mean drain output was 57.9ml. The drain group had significantly fewer patients with seroma on day 1 (6 vs 14, p=0.022) and day 6 (17 vs 30, p=0.000), and a smaller mean seroma size on days 1 and 6 (p=0.000). Subgroup analysis showed that sac ligation versus reduction, peritoneal perforation, and fixation adjuncts had no significant effects on seroma formation or size. There is a trend of lower early post-operation VAS score and more urinary retention in drain group was observed but not reaching statistical significance. No differences in postoperative pain score or complications were observed at 1 and 7months' post operation. Preperitoneal drainage for 23h after laparoscopic TEP hernioplasty for inguinal hernia can effectively decrease seroma formation in the early postoperative period, and potentially improving postoperative pain. The benefit is short-term and no significant difference was demonstrated after 1-month post operations. This tradition technique applied to novel operative repair of inguinal hernia is safe and feasible with no significant morbidity demonstrated. Preperitoneal drainage after TEP can be considered as an option to improve patient satisfactions and recovery in selected patient group for maximal benefit, especially for those with prolonged operation which may associate with higher chance of seroma formation.

Rolling method for mesh placement of laparoscopic total extra-peritoneal hernioplasty: A novel technique

Rolling method for mesh placement of laparoscopic total extra-peritoneal hernioplasty: A novel technique

Randomised controlled trial of n-butyl cyanoacrylate glue fixation versus suture fixation of mesh in laparoscopic totally extraperitoneal hernia repair.

BACKGROUND:We present a randomised control trial to compare suture fixation of the mesh with non-mechanical fixation using n-butyl cyanoacrylate (NBCA) glue for laparoscopic totally extraperitoneal (TEP) hernioplasty.PATIENTS AND METHODS:After a standard dissection for laparoscopic TEP hernioplasty, the mesh was fixed using sutures or NBCA glue to the Cooper's ligament as per the randomised allocation. The primary endpoints were recurrence at 24 months and chronic groin pain. The secondary endpoints were pain scores, analgesic requirement in the post-operative period and duration of surgery.RESULTS:Group A consisting of suture fixation had 127 patients which included a total of 173 hernias while Group B consisting of NBCA had 124 patients including a total of 171 hernias. The patients’ age, sex distribution, body mass indices and co-morbidities were comparable in both groups. No patient suffered any major intra-operative or post-operative complication or mortality. There were no conversions to open surgery in either of the groups. The operating time was similar in both the groups though there was a tendency toward a shorter surgery time in Group B. There was lesser consumption of analgesics in the immediate post-operative period in Group B but this did not reach statistical significance. Using visual analogue scale to measure pain, there was no difference in pain at 48 h; however, Group B patients complained of significantly less pain on day 7 as compared to Group A. Almost 98% of Group A patients and 99.2% of Group B patients completed 24 months of follow-up. There were no recurrences in either groups or was there any significant difference in chronic groin pain, in fact, none of the Group B patients complained of chronic groin pain.CONCLUSION:Using NBCA glue to fix the mesh in laparoscopic TEP hernia repair is effective and associated with less pain on day 7 as compared to suture fixation of the mesh.

A comparative study of transabdominal preperitoneal verses totally extra-peritoneal mesh repair of inguinal hernia

Background: Transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) mesh repair are two common procedures which are nowadays commonly performed during laparoscopic approaches for inguinal hernias. This randomized prospective study was aimed to compare these two, TAPP and TEP laparoscopic approaches for inguinal hernia repair in terms of various outcomes. Materials and Methods: Patients were randomly picked and 30 (50%) were operated by laparoscopic TAPP hernioplasty and the 30 (50%) by laparoscopic TEP hernioplasty. Results: Both TEP and TAPP mesh repair techniques were comparable in terms of operative time, intraoperative complications, conversion to open, post-operative pain, time to resume normal activity, and recurrence. Duration of hospital stay was significantly more in TAPP group than TEP group. Conclusion: Laparoscopic repair of inguinal hernias is associated comparable results in both techniques TAPP and TEPP and choice between TAPP and TEPP is a personal choice of the concerned surgeon.

A comparative study of transabdominal preperitoneal (TAPP) verses totally extra-peritoneal (TEP) Mesh repair of inguinal hernia

Background: Transabdominal preperitoneal (TAPP) and totally extra-peritoneal (TEP) mesh repair are two common procedures which are now a days commonly performed during laparoscopic approaches for inguinal hernias. This randomized prospective study was aimed to compare these two, TAPP and TEP laparoscopic approaches for inguinal hernia repair in terms various outcomes. Methods: Patients were randomly picked and 30 (50%) were operated by laparoscopic TAPP hernioplasty and the 30 (50%) by laparoscopic TEP hernioplasty. Results: Both TEP and TAPP mesh repair techniques were comparable in terms of operative time, intraoperative complications, conversion to open, post-operative pain, time to resume normal activity and recurrence. Duration of hospital stay was significantly more in TAPP group than TEP group. Conclusion; Laparoscopic repair of inguinal hernias is associated comparable results in both techniques, TAPP and TEPP and choice between TAPP and TEPP is a personal choice of concerned surgeon.

Randomized Double-Blinded Prospective Trial of Fibrin Sealant Spray Versus Mechanical Stapling in Laparoscopic Total Extraperitoneal Hernioplasty

The aim of the current study was to compare the clinical outcomes of mesh fixation with fibrin sealant (FS) spray or mechanical stapling (MS) in laparoscopic total extraperitoneal hernioplasty (TEP). The most appropriate method of mesh fixation is uncertain. Between June 2007 and June 2011, consecutive patients with primary reducible unilateral inguinal hernia who underwent day-case laparoscopic TEP were recruited. Outcome parameters included the incidence of acute and chronic pain, recurrence rates, morbidity rates, analgesic requirements, quality-of-life (QOL) scores, and direct cost. During the study period, 130 patients were included in the study. Patients in the MS group had significantly worse pain scores on the day after operation (P = 0.006). Analgesic requirements were similar between the 2 groups (P = 0.558). At 6 months, no significant differences in the incidence of chronic pain were observed (at rest, after coughing or cycling). The incidence of seroma formation was similar between the 2 groups (P = 0.64), and no recurrences were observed at 1 year. No differences in the QOL scores were detected. The direct cost of the entire hospitalization in the FS group was less expensive (P < 0.001). FS and MS are both effective methods of providing mesh fixation. FS was associated with reduced acute pain but not chronic pain. The rates of seroma formation were similar. However, the use of FS for mesh fixation was less expensive. [corrected].

Pre-emptive infiltration of Bupivacaine in laparoscopic total extraperitoneal hernioplasty: a randomized controlled trial

To investigate the effectiveness of pre-emptive preperitoneal infiltration of 0.5% Bupivacaine in postoperative pain control in laparoscopic total extraperitoneal (TEP) hernioplasty. We conducted a prospective randomized controlled three-arm study. Consecutive patients aged 18-75 years with reducible groin hernia undergoing laparoscopic TEP hernioplasty in our day surgery unit were recruited. They were randomized into three groups. The pre-emptive Bupivacaine group (PBU) received infiltration of 10 ml 0.5% Bupivacaine to port sites before skin incision and another 10 ml to the preperitoneal space immediately after the creation of a first working port before further dissection. The standard Bupivacaine group (SBU) received infiltration of Bupivacaine after mesh placement, while in the control group (CO), the same amount of saline was injected instead. All operations were performed with the same surgical technique by a single surgeon. Postoperative pain was recorded at 2, 6, and 24 h by an independent assessor using a 0-10 verbal rating scale. The operative time, complications, and analgesia consumption, as well as patient satisfaction were also measured. Ninety patients were randomized into three groups of 30. There were no differences in age, American Society of Anesthesiologists (ASA) risk classification, number of bilateral diseases, and operation time. The pain score was significantly reduced by Bupivacaine compared with control patients, while pre-emptive Bupivacaine was better than standard Bupivacaine. Fourteen out of ninety patients (15.6%) had seroma formation. All patients were discharged on the same day of operation. Pre-emptive preperitoneal infiltration of 0.5% Bupivacaine significantly reduces postoperative pain in laparoscopic TEP hernioplasty.