Totally Extraperitoneal Procedure Research Articles

Navigating hernia sac management in minimally invasive inguinal hernia repair: to abandon or to reduce? An updated systematic review and meta-analysis.

Minimally invasive inguinal hernia repair has become increasingly accepted, demonstrating superior outcomes over open procedures in postoperative complications. However, certain postoperative complications, such as seroma, remain a dilemma, with many attributing it to the management of the hernia sac. We aimed to perform a systematic review and meta-analysis comparing the reduction versus abandonment of the hernia sac during laparoscopic inguinal hernia repair. Cochrane, Scopus, SciELO, and PubMed were searched for studies comparing reduction and abandonment of the hernia sac. Our primary outcome was seroma. Secondary outcomes were overall complications, postoperative pain, surgical site infection, recurrence, hospital length of stay (LOS), and operative time. We performed a subgroup analysis of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques. Statistical analysis was performed with R Studio. 2388 studies were screened, and seven studies were included, comprising 3153 patients, of which 916 (29%) were in the abandonment group. We found higher seroma rates for the abandonment group (RR 1.52; 95% CI 1.22 to 1.89; P < 0.001). No differences were found in overall complications (RR 0.88; 95% CI 0.55 to 1.42; P = 0.61), postoperative pain (RR 1.15; 95% CI 0.46 to 2.87; P = 0.76), recurrence (RR 2.67; 95% CI 0.51 to 14.05; P = 0.25), operative time (MD -4.45 min; 95% CI -12.77 to 3.86; P = 0.29), and LOS (MD -0.06 days; 95% CI -0.14 to 0.02; P = 0.14) between both groups. Subgroup analysis of seroma showed no differences between the groups when analyzing TAPP (19.3% vs. 13%; RR 1.65; 95% CI 0.91 to 2.99; P = 0.1) and TEP (9% vs. 4.3%; RR 1.69; 95% CI 0.62 to 4.6; P = 0.3) procedures. Our systematic review and meta-analysis support that hernia sac abandonment may be associated with increased early seroma rates following laparoscopic inguinal hernia repair, but limited data are available for technique-specific analyses.

Laparoscopic Hernia Repair: Tapp Versus Tep. A Single Centre Experience

Summary Surgery for inguinal hernia is currently the most common surgical procedure worldwide, and every year over 20 million patients undergo open or laparoscopic hernia repair. Two generally accepted endoscopic approaches are transabdominal preperitoneal procedure (TAPP) and total extraperitoneal procedure (TEP). For nine years (2010 – 2018), 48 patients with inguinal hernia had laparoscopic hernia repair (TAPP or TEP) at Villarobledo General Hospital. Forty-three patients (89.6%)) were male, and five (10.4%) were female. Of these, ten had right inguinal hernia (RIH), 18 - left inguinal hernia (LIH), 12 - bilateral inguinal hernia (BIH), 6 had recurrent unilateral inguinal hernia (RUIH), and 2 had recurrent bilateral inguinal hernia (RBIH). In 33 patients (68.7%), transabdominal preperitoneal laparoscopic hernia repair (TAPP) was performed. Total extraperitoneal laparoscopic hernia repair (TEP) was performed on 15 patients (12%). In 8 patients (16.6%), simultaneous surgical procedures were performed: umbilical hernioplasty in 4 (8.3%) patients and laparoscopic cholecystectomy in 4 (8.3%) patients. There were no conversions in any of the surgical procedures. The average operative time was 77 minutes. Twenty-six patients underwent one-day surgery, 18 were in the hospital for one day, and four patients were discharged on the second postoperative day following surgery. In 7 patients (14%), recurrences occurred: in the first postoperative year - 1 patient; in the second year after surgery - 3 patients; in the third after surgery - 2 patients; and in the sixth year - 1 patient. The recurrence rate was 2 in 33 patients after TAPP (6%) versus 5 in 15 patients after TEP (33%), Chi-squared=5.91 (p=0.015). In one patient, perforation of the bladder occurred after TEP and was managed conservatively using a urethral catheter and preperitoneal drainage. TAPP and TEP had a considerable discrepancy in recurrence rates. Such discrepancy in recurrences is probably due to the higher complexity of the TEP technique and the required supervising of experienced surgeons during the learning curve.

SJLA_2024_A17: Use of Perioperative Tamsulosin to Prevent Postoperative Urinary Retention Following Day Case Laparoscopic Inguinal Hernia Repair

Postoperative urinary retention is one of the more common complications following laparoscopic inguinal hernia repair (LIHR). We hypothesized that the oral one adrenergic blocker Tamsulosin, (Flomax, Boehringer Ingelheim) could be used to decrease the incidence of urinary retention after LIHR. Data from all patients undergoing laparoscopic total extraperitoneal (TEP) inguinal hernia repair by a single surgeon from June 2012 through June 2017 were collected prospectively. Patients received Tamsulosin (Flomax) 0.4 mg/day orally for a total of 5 days beginning 2 days before surgery. All TEP procedures were done under general anesthesia without a urinary catheter in place. Patients were discharged home after voiding in the recovery area. Data are expressed as mean ± standard deviation; flomax was administered to 30 of 32 consecutive patients undergoing outpatient TEP inguinal hernia repair. The mean patient age was 51.3 ± 10.5 years (28–72 years). Ten (32.2%) patients were operated on for recurrent inguinal hernias, 14 (45.1%) had bilateral hernias repaired, and 4 (12.9%) had concomitant umbilical hernia repair. The average operative time was 60 ± 24 min. The mean amount of intraoperative fluids given was 998 ± 297 ml. Two patients were excluded from the study because they required a urinary catheter in the operating room for other reasons (one requiring concomitant cystoscopy and one with anticipated complicated repair in patients who had three prior open inguinal hernia repairs and did not take Flomax). None of the patients given Flomax perioperatively developed urinary retention and all were discharged home the same day of surgery. In contrast, the two patients undergoing TEP repairs who did not receive Flomax perioperatively both developed urinary retention that required catheter placement.

Our Experiences and Comparison of Total Extraperitoneal (TEP) And Transabdominal Preperitoneal (TAPP) Techniques in Laparoscopic Inguinal Herni Repair

Aim: In this study, it was aimed to compare the results of Total Extraperitoneal (TEP) and Transabdominal Preperıtoneal (TAPP) surgical methods in laparoscopic inguinal hernia repair.&#x0D; Methods: The data of 317 patients who underwent laparoscopic inguinal hernia repair surgery with the diagnosis of inguinal hernia between October 2016 and January 2021 in the General Surgery Clinic of SBU Sultan 2. Abdulhamid Han Training and Research Hospital were evaluated retrospectively. The wound dehiscence, swelling in the incision or scrotum, recurrence, and the postoperative day of returning to work were questioned. The results of TAPP and TEP methods were compared statistically.&#x0D; Results: In our study, the mean age of 317 patients who underwent surgery with TEP and TAPP methods was 50.5, and 27 of them were female and 290 were male. Postoperative recurrence was observed in 21 (6.6%) patients, wound dehiscence in 11 (3.4%) patients, swelling at the incision in 44 (13%) patients, and scrotal swelling in 30 (9.4%) patients. It was determined that the patients who underwent the TEP procedure returned to work after an average of 5.09 (1-30) days, and the patients who underwent the TAPP procedure after an average of 4.04 (1-14) days. When the two groups were compared, there was no significant difference between the groups in terms of return to work day in the postoperative period (p= 0.707), recurrence in the postoperative period (p=0.493), swelling at the incision (p=0.479), scrotal swelling (p=0.356), and wound dehiscence (p=0.245).&#x0D; Conclusions: There are two methods commonly used today in the repair of inguinal hernia by laparoscopic method. TEP method is performed in the preperitoneal area and TAPP method is performed in the intraperitoneal area. In this study, the results of TEP and TAPP methods were compared and it was found that there was no statistically significant difference between the two procedures in terms of postoperative recurrence, time to return to work and postoperative complications.

Transinguinal preperitoneal (TIPP) vs endoscopic total extraperitoneal (TEP) procedure in unilateral inguinal hernia repair: a randomized controlled trial

PurposeThe Lichtenstein hernioplasty has long been seen as the gold standard for inguinal hernia repair. Unfortunately, this repair is often associated with chronic pain, up to 10–35%. Therefore, several new techniques have been developed, such as the transinguinal preperitoneal patch (TIPP) and the endoscopic total extraperitoneal (TEP) technique. Several studies showed beneficial results of the TIPP and TEP compared to the Lichtenstein hernioplasty; however, little is published on the outcome when comparing the TIPP and TEP procedures. This study aimed to evaluate outcomes after the TIPP vs the TEP technique for inguinal hernia repair.MethodsA single-center randomized controlled trial was carried out between 2015 and 2020. A total of 300 patients with unilateral inguinal hernia were enrolled and randomized to the TIPP- or TEP technique. Primary outcome was chronic pain (defined as any pain following the last 3 months) and quality of life, assessed with Carolinas comfort scale (CCS) at 12 months. Secondary outcomes were: wound infection, wound hypoesthesia, recurrence, readmission within 30 days, and reoperation.ResultsA total of 300 patients were randomized (150 per group). After a follow-up of 12 months, we observed significantly less postoperative chronic groin pain, chronic pain at exertion, wound hypoesthesia, and wound infections after the TEP when compared to the TIPP procedure. No significant differences in quality of life, reoperations, recurrence rate, and readmission within 30 days were observed.ConclusionWe showed that the TEP has a favorable outcome compared to the TIPP procedure, leading to less postoperative pain and wound complications, whereas recurrence rates and reoperations were equal in both the groups.

Laparoscopic Totally Extraperitoneal (TEP) Groin Hernia Repair in Patients After Contralateral TEP Groin Hernia Repair.

The totally extraperitoneal (TEP) repair for groin hernia is considered difficult in patients with a healed surgical scar in the lower abdomen. We reported the feasibility of repair in those patients and found that the most frequent previous procedure in patients for whom the procedure was changed intraoperatively was a contralateral TEP after TEP repair. We now report an expanded patient cohort with a suggested unified treatment strategy. From 2006 to 2020, 443 patients underwent laparoscopic TEP groin hernia repair. A contralateral TEP after TEP repair was performed in 35 patients. The conversion rate after TEP was compared with that after other operations. Patients were divided into completed contralateral TEP after TEP repair (N=28) and changed procedure groups (N=7). Clinical characteristics were compared including age, body mass index, location and type of hernia, and interval after previous surgery. Multivariate analysis was performed to evaluate risk factors for conversion of the TEP procedure. Patients undergoing contralateral TEP after TEP repair were significantly overrepresented among patients for whom the procedure was changed compared with other previous operations (P<0.01), with an odds ratio of 19.91. Comparing completed TEP after TEP repair and changed procedure groups, there were no significant differences regarding age (mean: 67 vs. 69 y old), body mass index (22.4 vs. 22.5 kg/m2), type of hernia (indirect or direct), or duration after previous TEP repair (median: 642 vs. 470 d) and identified no significant risk factors. The contralateral TEP after TEP repair for groin hernia is feasible. However, dense adhesions may be present if balloon dissection was performed at the previous TEP repair, and it is necessary to carefully dissect being ready to convert to other procedures such as TAPP repair or an anterior approach.

Outcomes of Endoscopic Totally Extraperitoneal (TEP) repair of clinically occult inguinal hernia diagnosed with ultrasonography.

Inguinal hernias generally present with groin lump and pain. Although inguinal hernias can be diagnosed clinically in most cases, patients without a groin lump pose a considerable diagnostic challenge. The first-line diagnostic imaging tool in these cases is ultrasound (US) and the recommended surgical procedure is laparoscopic-endoscopic repair. This retrospective study aims at evaluating postoperative results and complication rates of TEP technique in patients with occult contralateral hernias diagnosed with US in comparison to patients with clinically diagnosed hernias. A retrospective study was conducted to evaluate the outcomes of TEP procedure in patients with radiologically diagnosed occult contralateral hernias in comparison to patients with clinically diagnosed hernias. All hernias included in this study were repaired by TEP technique and secured with an extraperitoneal mesh. Demographic data, patient characteristics and perioperative information were obtained by reviewing medical records. A total number of 109 patients were enrolled in the study. The majority of patients were male and the mean age was 48.9 ± 14.6 years. In 56 cases, hernias were repaired unilaterally, while the remaining 53 were repaired bilaterally. Right-sided hernias were more common than left-sided hernias. The morbidity rate was 7.1% in unilateral repairs and 3.8% in bilateral repairs. The recurrence rate was 3.6% for unilateral repairs and 5.7% for bilateral repair. Some studies report that the incidence of clinical contralateral inguinal hernias identified after primary unilateral surgery is approximately 10%. If these contralateral hernias were diagnosed prior to the primary surgery, the risk of performing another operation could be avoided. Laparoscopic surgery enables bilateral hernia repair without any additional incisions, presenting similar morbidity rates when compared to unilateral repair. There was no significant difference between unilateral and bilateral TEP repair in terms of intraoperative and postoperative surgical complications. These results suggest that laparoscopic inguinal hernia repair is a safe and effective surgical technique for both unilateral and bilateral procedures. In order to prevent second operation, all patients with suspected inguinal hernia should undergo an US examination before surgery.

Effect of carbon dioxide pneumoperitoneum on acid-base balance during laparoscopic inguinal hernia repair: a prospective randomized controlled study.

In this study, we aimed to compare the effects of CO2 pneumoperitoneum on acid-base balance during transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) procedures for repair of inguinal hernias. The study cohort comprised 100 patients who underwent repair of primary inguinal hernias from 1 June to 30 November 2019. The patients were randomly allocated to TAPP and TEP groups. Their acid-base balance was analyzed by comparing the results of blood gas analysis before and after the operative procedures and dynamic transcutaneous CO2 (TcCO2) changes during the procedures. There were no statistically significant differences among groups in demographics, including sex, age, and hernia type. There were also no significant differences between the two groups in anesthesia time, incidence of perioperative complications, or type of management of the hernia sac (all P > 0.05). The operation time was shorter for the TEP than the TAPP group (P < 0.01). In terms of CO2 metabolism and acid-base balance, the following differences between the two groups were statistically significant: changes in PaCO2 (7.54 ± 3.36 vs. 20.36 ± 7.60mmHg, P < 0.01), changes in TcCO2 (8.86 ± 3.57 vs. 17.40 ± 8.03mmHg, P < 0.01), rate of change in TcCO2 (0.22 ± 0.11 vs. 1.03 ± 0.56, P < 0.01), and changes in pH (- 0.05 ± 0.28 vs. - 0.15 ± 0.76, P < 0.01). TAPP and TEP can achieve good results in the treatment of inguinal hernia. Although no serious complications occurred, TEP procedures may cause more serious CO2 accumulation and quicker acidosis than TAPP procedures.

Laparoscopic Total Extraperitoneal Inguinal Hernia Repair Under Epidural Anesthesia Versus General Anesthesia.

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is a well-known approach to inguinal hernia repair. The present study aims to compare the advantages and disadvantages of the TEP technique under general anesthesia (GA) and epidural anesthesia (EA). The patients were divided into 2 groups as those undergoing TEP under EA (Group 1) and those undergoing TEP under GA (Group 2). The 2 patient groups were compared in terms of sex, age, body mass index data, duration of surgery, total operation time, patient satisfaction, VAS scores (1, 4, 12, and 24 h), length of hospital stay, and postoperative complications. The number of patients operated under EA (Group 1) was 30, and the number of patients operated under GA (Group 2) was 32. Only in the postoperative first hour VAS scores was statistically significantly less and the need for analgesia evaluated in both groups was found to be statistically significantly lower in Group 1 (P<0.001). The mean operation time was recorded as 62 and 46.50 minutes in Groups 1 and 2, respectively, which was statistically significantly shorter in Group 2 (P<0.001). There was no difference between the 2 groups regarding complications, hospital stay, recovery, or surgery time. Conversion rate is 0 in both groups. Lower postoperative VAS scores and lower postoperative VAS scores and lower analgesic used requirements of EA, it is thought that EA can be safely applied in the TEP procedure as an alternative in patients who cannot be administered GA.

Comparison of Lichtenstein versus laparoscopic total extra peritoneal method in inguinal hernia surgery: a retrospective study

Background: Inguinal hernias is known to be most common form of abdominal wall hernias and research studies suggested that 3 out of 4 patients of abdominal wall hernias are diagnosed with inguinal hernia. Inguinal hernioplasty is considered to be second most common general surgical operation worldwide and it accounts approximately 15% of all operations. This retrospective study is designed with aim that to compare open Lichtenstein hernia repair and laparoscopic totally extraperitoneal (TEP) hernia repair in patients with inguinal hernias. The result of the study helps to general surgeons to select the better method to treat inguinal hernias.Methods: This was a retrospective study which was carried out at General Surgery department, Dr. M.K. Shah Medical College and Research Centre, Ahmedabad. Total 100 patients’ data were included in the study that has fulfilled inclusion and exclusion criteria of the study.Results: In present study majority of the patients of both the group are in their 5th decade of their age. It was found that majority of the cases had right side hernia as compare to left side hernia. It was found that mean operative time for bilateral hernia is comparatively higher in Lichtenstein as compared to TEP.Conclusions: Lichtenstein procedure has less postoperative complications like abdominal distension, seroma and urinary infections. Laparoscopic TEP procedure is having less operative time particularly in bilateral hernia, less postoperative pain, early mobilization and early return to work.

Evaluation of the Reliability, Utility, and Quality of Information Used in Total Extraperitoneal Procedure for Inguinal Hernia Repair Videos Shared on WebSurg.

PurposeThe Internet is widely used by patients and physicians for obtaining medical information. WebSurg is a valuable information resource that can improve the learning experience of medical professionals if used appropriately. This study aimed to evaluate the quality and accuracy of videos on the total extraperitoneal procedure (TEP) for inguinal hernia repair.MethodsWe included 32 videos returned by the WebSurg search engine in response to the keyword “TEP.” Video popularity was evaluated using the video power index (VPI). The videos’ educational quality was measured using the DISCERN score, Journal of American Medical Association (JAMA) benchmark criteria, and Global Quality Score (GQS). Technical quality was measured using the TEP Scoring System (TepSS) by three surgeons who performed TEP routinely.ResultsAll videos were obtained from medical doctors; 12.5% of the videos were uploaded from Belgium; 3.1%, China; 6.3%, Colombia; 6.3%, England; 59.4%, France; 9.4%, Germany; and 3.1%, Korea. No significant differences were noted in terms of the VPI, DISCERN scores, JAMA benchmark criteria, GQSs, and TepSS scores (p > 0.05). The mean VPI, DISCERN score, JAMA benchmark criteria, GQS, and TepSS score were 9454.53 ± 15085.57, 32.75 ± 6.99, 2.31 ± 0.47, 1±0, and 9.25 ± 2.36, respectively. No significant associations were noted between the VPI and DISCERN score, JAMA benchmark criteria, and GQS (p > 0.05). Similarly, there was no significant association between the VPI and TepSS scores (r = 0.100; p = 0.587).ConclusionsThe online information on TEP is of suboptimal quality. Although limited information is available on preoperative and postoperative processes, the educational potential of WebSurg cannot be ignored.

Early results of comparison of polypropylene mesh and 75% resorbable mesh (monofilament polypropylene and poly-L-lactic acid (PLLA) mesh) for laparoscopic total extraperitoneal (TEP) inguinal hernia repair.

OBJECTIVE:Laparoscopic totally extraperitoneal (TEP) hernia repair has become increasingly widespread. Faster recovery than conventional open methods shortens the return to work. Polypropylene (PP) mesh is still in use in hernia surgery because it is an inexpensive and easily accessible patch. The post-operative chronic pain and foreign body sensation are the disadvantages of these PP patches. Poly-L-lactic acid and polypropylene (PLLA) were used in this study because of the good biocompatibility and low tissue inflammation response. We compared the early clinical outcomes of PP patch and PLLA patches.METHODS:Between January 2013 and April, 2018,469 patients with inguinal hernia underwent TEP procedure. Patients were divided into two groups. PP mesh (n=211) in group 1, PLLA mesh (n=258) in group 2. Patients were compared regarding age, gender, hernia side, ASA scores, the duration of operation, pain, time to return to work, the sensation of foreign body, seroma and hematoma.RESULTS:A total of 469 patients were analyzed retrospectively (426 male, 43 female). The mean age was 52.23±13.66 years. The operative times of the patients were 40.92±8.9 minutes in group 1, and 38.82±8.5 minutes in group 2 (p<0.05). The time to return to work was 10.2±1.47 days in Group 1 and 8.4±1.0 days in Group 2 (p<0.05). Visual Analog Scale (VAS) in group 2 was lower than in group 1 (p<0.005). In group 2, the feeling of the organic body decreased in the early and late period (p<0.005). Seroma and hematoma were less in Group 2 than in Group 1 (p<0.005). The mean follow-up period of the patients was 18 (3-63) months, two patients in Group 1, two patients in Group 2 recurred.CONCLUSION:The PLLA patch used in the TEP method is thought to be a herniated patch that can be safely used because of its ease of application and less postoperative complication rates and more rapid return to work.

Laparoscopic transperitoneal inguinal hernioplasty (TAPP) after radical open retropubic prostatectomy: special features and clinical outcomes.

Purpose Laparoscopic transperitoneal endoscopic (TAPP) and totally extraperitoneal (TEP) hernia repair have been well established in primary and recurrent inguinal hernias [1]. Only few studies [2-5] evaluate the surgical outcome of patients with inguinal hernias after radical prostatectomy, using the TAPP or TEP procedure. But controversies remain including its feasibility, safety and recurrence rate. The mesh size to be used and the necessity of a complete dissection of the scared retropubic space are discussed controversially. Long-term follow-up studies are missing.Methods After introducing the technique of a laparoscopic transperitoneal endoscopic hernioplasty (TAPP) at the hospital in October 1992, this approach had been recommended to all adult patients with inguinal and femoral hernias. In our single-center study, the medical records of all 5,764 patients with 7,010 inguinal and femoral hernias, operated from 1993 until 2009, were enrolled in a retrospective analysis. A TAPP procedure was performed in 6,582 hernias (Peitsch, Surg Endosc 28:671-682, 2014). During that period, 48 patients with 55 inguinal hernias on average of 3.7years (3 months-14years) after prior open radical retropubic prostatectomy underwent hernia surgery (92.7% TAPP). The age of these patients, time required for surgery, hernia location (medial, lateral, combined and bilateral), the perioperative (30-day complications "Clavien Classification") and late complications with a median postoperative follow-up time of 8.0years (2-17years) were analyzed and compared with the data of the control group (all TAPP procedures for inguinal and femoral hernias).Results Patients with inguinal hernias after radical open retropubic prostatectomy were older as patients of the control group (70.3 vs. 59.1years) and the medial time required for surgery was significantly longer (72.9 vs. 41.3min). Less frequent were bilateral inguinal hernias (25.5 vs. 35.8%), medial inguinal hernias (Hernia classification Nyhus Type 3A) with 5.5 vs. 17.9% and femoral hernias (0 vs. 4.9%). No hernia patient after radical prostatectomy and only 0.1% of the control group (n = 6582 hernias) had a conversion to an anterior open repair. One patient after radical prostatectomy needed a laparoscopic drainage of a hemato-seroma 48h postoperatively (1/51). The rate of late postoperative complications was low. 4.8% of patients reported of groin pain and 2.4% of testicular pain longer than 28days postoperatively. The hernia recurrence rate of 2.4% (1/42 TAPP) was not significantly different from the control group (1.8%, 16/896 hernias).Conclusions In the hands of surgeons with large experiences in endoscopic laparoscopic hernia repair, the laparoscopic transperitoneal hernioplasty (TAPP) after previous radical open retropubic prostatectomy is safe and effective with low intra- and postoperative complications and low hernia recurrences (2.4%). A TAPP technique with closure of hernia gaps larger than 1 × 1cm with non-absorbable surgical sutures and a mesh-size of 13 × 13-15cm is requested. A complete sharp dissection of the retropubic scared tissue for mesh implantation is not mandatory.

Is laparoscopic totally extra peritoneal repair of hernia (TEP) superior than trans-abdominal preperitoneal (TAAP) mesh repair of inguinal hernia- our experience from a tertiary care hospital, Kolkata

Background: The most common laparoscopic techniques for inguinal hernia repair are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. In TAPP a mesh is placed through peritoneal incision over possible sites of hernia by going into peritoneal cavity, where as in TEP the peritoneal cavity is not entered and a mesh is used to seal the hernia from outside the peritoneum.Aims and Objectives: The aim of the current study was to compare the outcome of Total Extra- peritoneal (TEP) versus Trans-abdominal Pre-peritoneal (TAPP) repair of inguinal hernia, where both can be done.Materials and Methods: The current randomized control study was conducted among eighty patients of inguinal hernia. Of these, the sampling was done through random allocation of patients for TEP (Group-I) and TAPP (Group-II), comprising forty patients in each group. All patients irrespective of group were observed for pain (by VAS Score), mean operative time, duration of hospital stay, days taken to resume their normal activities, intra-operative and early post-operative complications and recurrence if any.Results: The pain in both groups was insignificant until one day but highly significant differences (p&lt;0.0001) were observed by end of day 2 and 1 month, showing higher degree of pain in TAPP with respect to TEP procedure. The differences in mean operative time for surgery was highly significant (p&lt;0.0001) with mean time of 86.72 min (TAPP) and 99.72 (TEP). The duration of hospital stay was higher in TAPP (5.2 days) compared to TEP (2.6 days). The mean time to return to normal activities was 10.8 days (TAPP) and 6.2 days (TEP) which was highly significant (p&lt;0.0001). The recurrence though occurred only in one patient in TEP group which was negligible. The other post-operative complications was seroma (8 cases; TAPP) versus (1 case; TEP) and it was highly significant (p&lt;0.0001). The port site infection was in 20 % patients (8/40) in TAPP compared to 2.5% (1/40) in TEP group.Conclusion: The TEP is comparatively superior than TAPP procedure in terms of post-operative complications, duration of hospital stay and return to normal activities.Asian Journal of Medical Sciences Vol.9(6) 2018 20-24

An 11-year analysis of reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high volume hernia center.

Developments in inguinal hernia surgery have substantially lowered recurrence rates, yet recurrences remain an important outcome parameter of inguinal hernia repair. The aim of this study was to analyze the characteristics of all reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high-volume hernia clinic in the Netherlands. All groins with recurrence-like symptoms reoperated after previous TEP inguinal hernia repair between January 2006 and December 2016 were analyzed. Patient characteristics, imaging findings, primary hernia type, time to recurrence and recurrence type were assessed. A total of 137 groins were reoperated in 130 patients. The median age at the TEP procedure was 55years [interquartile range (IQR) 45-64years]. Fifty-seven groins were initially part of a bilateral procedure (42%). Median time until recurrence was 9months (IQR 4-26months). Reoperation findings were a hernia recurrence in 76%, an isolated lipoma in 18%, and no recurrence or lipoma in 6%. The majority of hernias recurred at their initial site (70%), of which the greatest part involved direct hernias. Isolated lipomas were more frequently seen after indirect hernia repair. Inguinal hernia recurrences were still observed in this high-volume hernia clinic. Recurrences were most frequently seen at their initial hernia site, the majority involving direct hernias. Isolated lipomas presenting as a pseudorecurrence were most frequently seen after correction of indirect hernias. In accordance with the current guidelines, reducing recurrence rates can be achieved by mesh fixation in bilateral, large and direct defects and by thoroughly reducing lipomas.

Laparoscopic inguinal hernia repair in elderly patients: single center experience in 12 years

Background: To evaluate the clinical outcome of laparoscopic inguinal hernia repair (LIHR) in elderly patients. Methods: The clinical data of 3,203 cases (3,847 hernias) un-derwent LIHR from January 2001 to December 2013 were analyzed retrospectively. There were 1,677 transabdominal preperitoneal (TAPPs) in 1,475 cases, 2,154 total extraperito-neal (TEPs) in 1,718 cases and 16 intra-peritoneal onlay mesh (IPOMs) in 10 cases. All procedures were performed by the same surgical team and the choice of techniques was made by the surgeons. The follow-up period ranged from 23 to 60 months (median 43 months). Results: The hernias in elderly patients aged over 60 years ac-counted for 69.4%. These patients had more bilateral hernia, direct hernia and complex hernia than patients younger than 60 years (P=0.000, 0.000), more grade III hernia and grade IV hernia (P=0.000). There were more TEP and IPOM procedures in elderly patients (P=0.000), of which IPOMs were all used in recurrent hernias. There were more heavy-weight meshes used in elderly patients (P=0.000). No significant differences were found in operation time, visual analogue scales (VAS), postoperative hospital stay, cases returned to normal activities in 2 and 4 weeks between the two groups (P>0.05). There were no significant differences in recurrence rate and overall complication rate between the two arms (P>0.05), of which, there were more urinary retention in elder cases (P=0.008). No significant differences were found in seroma, transient paresthesia and ileus between two groups (P>0.05). Conclusions: LIHR is a safe and efficient technique in elderly patients. With reasonable application, LIHR can achieve good clinical outcome.

A comparative study of totally extraperitoneal versus transabdominal preperitoneal repair of inguinal hernias

Background: The two common procedures which are nowadays commonly performed for laparoscopic repair of inguinal hernia are transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) mesh repair. This retrospective study was aimed to compare these two, TAPP and TEP laparoscopic approaches for inguinal hernia repair in terms of various outcomes.Methods: In this retrospective study, we included 50 cases of inguinal hernia who underwent laparoscopic approach of inguinal hernia repair at Saveetha medical college and hospital between 2014 and 2016 for a duration of 3 years. Various parameters including the age, sex of patient, type of hernia, preoperative and post-operative complications, duration of hospital stay was analysed.Results: Of the 50 patients who underwent laparoscopic repair, 26 patients underwent TEP and 24 patients under went TAPP procedure. 31 cases were indirect inguinal hernias and 30 cases were direct inguinal hernias, totalling 61 hernia repairs, as 11 patients had bilateral hernia. One female inguinal hernia and 4 cases of recurrent hernia were operated by TAPP method. Postoperative complications like seroma formation; subcutaneous emphysema was seen in TEP group. Two cases of TEP were converted to TAPP and open lichenstein procedure. Postoperative pain was less in both the group. Patients who underwent TEP procedure spent less time in the hospital compared to those who underwent TAPP procedure.Conclusions: There is no major difference in the outcome after TEP and TAPP surgeries except for some minor complications and the results are comparable in both techniques TAPP and TEP. Both the procedures can be practiced according to surgeon’s familiarity of the procedure.

Laparoscopic Single-Site Inguinal Hernia Repair Using a Self-Fixating Mesh.

Background and Objectives:Every year ∼20 million inguinal hernia repairs are completed worldwide. Increased patient access to medical information and education has elicited interest in minimally invasive surgical techniques that obtain improved surgical outcomes and cosmesis. Because of these factors, there is a growing interest in single-incision surgery. Laparoscopic totally extraperitoneal (TEP) single-incision hernia repair technique has been reported with different meshes used in a tack fixation system. Recently, self-fixating mesh technology has offered the possibility of avoiding tack fixation and potentially avoiding chronic postoperative pain. Self-fixating mesh technology employs monofilament polylactic acid (PLA) creating a microgrip system that provides self-adherence of the mesh to adjacent tissue. This tack-free fixation system provides coverage over the entire myopectineal orifice and surrounding areas where traditional tacks cannot be placed. Self-fixating mesh has also been safely applied in laparoscopic TEP procedures, but this mesh has not been described in single site TEP surgery; possibly because of the potential difficulty with mesh deployment. We sought to determine the technical feasibility of a single-site laparoscopic TEP repair of inguinal hernias and to discuss our techniques and patient short-term outcomes.Methods:Review of a prospectively maintained database of patients who received single-site laparoscopic TEP herniorrhaphy from August 2012 through August 2015. Patient characteristics and demographics and perioperative and postoperative data were analyzed.Results:Thirty-four patients (aged 55.2 ±14.2; 17.6% women) with a mean body mass index of 26.2 ± 3.9 were analyzed. Mean operative time was 99.5 ± 30.5 minutes, 41.2% were left-side repairs, and 50% were bilateral. Estimated blood loss was 18.4 ± 14.1 mL. Recurrent hernias accounted for 14.7% of cases; 32.4% of cases were combination surgeries, most commonly a concurrent umbilical hernia repair. The most common short-term postoperative complication was urinary retention (4 patients). The median length of follow-up was 25 days (IQR 18.75–61.75). Complications occurring at >30 days included hydrocele (2 patients) and stitch abscess (1 patient). Eight (23.5%) patients had complications (surgical or during follow-up). No recurrences or deaths were reported.Conclusions:With comparable operative times, perioperative outcomes, and safety profile, SS-TEP appears to be a safe and effective surgical approach for the management of inguinal hernias in the short term. Furthermore, SS-TEP with a self-fixating mesh is a feasible approach.

Total Extraperitoneal Hernia Repair: Residency Teaching Program and Outcome Evaluation

Total extraperitoneal (TEP) hernia repair has been shown to offer less pain, shorter postoperative hospital stay and earlier return to work when compared to open surgery. Our institution routinely performs TEP procedures for patients with primary or recurrent inguinal hernias. The aim of this study was to show that supervised senior residents can safely perform TEP repairs in a teaching setting. All consecutive patients treated for inguinal hernias by laparoscopic approach from October 2008 to June 2012 were retrospectively analyzed from a prospective database. A total of 219 TEP repairs were performed on 171 patients: 123 unilateral and 48 bilateral. The mean patient age was 51.6years with a standard deviation (SD) of±15.9. Supervised senior residents performed 171 (78%) and staff surgeons 48 (22%) TEP repairs, respectively. Thirty-day morbidity included cases of inguinal paresthesias (0.4%, n=1), umbilical hematomas (0.9%, n=2), superficial wound infections (0.9%, n=2), scrotal hematomas (2.7%, n=6), postoperative urinary retentions (2.7%, n=6), chronic pain syndromes (5%, n=11) and postoperative seromas (6.7%, n=14). Overall, complication rates were 18.7% for staff surgeons and 19.3% for residents (p=0.83). For staff surgeons and residents, mean operative times for unilateral hernia repairs were 65min (SD±18.9) and 77.6min (SD±29.8) (p=0.043), respectively, while mean operative times for bilateral repairs were 115min (SD±40.1) and 103.6 (SD±25.9) (p=0.05). TEP repair is a safe procedure when performed by supervised senior surgical trainees. Teaching of TEP should be routinely included in general surgery residency programs.

Low Pressure is Necessary to View and to Protect Corona Mortis During Totally Extraperitoneal Hernia Repair.

The identification of retropubic vasculature is not easy under the pressure of insufflated gas during totally extraperitoneal (TEP) inguinal hernioplasty. We aimed to present the usefulness of a maneuver that allows the clear identification of retropubic vasculature. Vascular anatomy on the retropubic surface in 364 patients who underwent the TEP procedure from January 2005 to September 2015 was evaluated. In patients after July 2014, the pressure in the workspace was decreased from 14 to 8 mmHg before fixation of the mesh to clearly identify the veins. The results before and after July 2014 were compared. Demographic features were not significantly different between two periods. The number of hemipelvises in the first and second periods was 398 and 77, respectively. The rate of identification of venous corona mortis was 31% in the second period, whereas it was 1.0% in the first period (P = .000). The identification of thick (5.5% versus 10.3%; P = .123) and thin (22.8% versus 36.3%; P = .014) arterial structures and their sum were increased in the second period (28.4% versus 46.7%; P = .002). The rate of retropubic bleeding was zero in the second period, while it was 1.5% in the first period. During TEP hernioplasty, the pressure of insufflated gas more than 10 mmHg in the preperitoneal space hinders the correct identification of vessels on the retropubic surface. The proposed maneuver, to decrease the pressure in the workspace to 8 mmHg, can provide clear identification of all vessels, which decreases the potential risk of vascular injury.