Totally Extraperitoneal Procedure Research Articles

Corona mortis: in vivo anatomical knowledge and the risk of injury in totally extraperitoneal inguinal hernia repair.

Corona mortis (CMOR) is the arterial and/or venous vascular communication(s) between the obturator and external iliac vessels. Totally extraperitoneal (TEP) inguinal hernioplasty can be associated with vascular complications especially during the fixation of the mesh. Theoretically, CMOR is an important nominee. But, the data in literature are insufficient about CMOR injury. Additionally, most of the studies about CMOR have been usually performed on cadavers. We aimed to reveal the preperitoneal vascular anatomy of inguinal area and provide in vivo knowledge about CMOR. The risk of arterial injury was also evaluated. The data of preperitoneal vascular anatomy of 321 patients who underwent TEP procedure between January 2005 and July 2014 were retrospectively evaluated. Mean age was 46±8.9years, 53 females vs 268 males. 391 hemipelvises were evaluated. Two types of arterial structure were identified; (1) an aberrant obturator artery forming an anastomosis with branches of ordinary obturator artery; (2) a pubic branch of inferior epigastric artery. The incidence of arterial CMOR was 28.4% and of any arterial structure was 45.0%. An arterial CMOR was considered as thick (≥2mm) or thin (<2mm). Injury of arterial CMOR during tack stapling on Cooper's ligament was seen in six cases (1.5%). All of them were thin (<2mm) in structure. Venous CMOR was visible only under low pressure in work space. During TEP hernia repair, CMOR and/or pubic branch of inferior epigastric artery can be damaged. To prevent this complication, tacks should be stapled to Cooper's ligament close to symphysis pubis and dissection should be careful on the posterior surface of superior pubic ramus. Small caliber (<2mm) arterial CMOR is more prone to be injured during TEP procedure. To explore venous structures properly, pressure in workspace should be kept as low as possible.

Totally extraperitoneal (TEP) endoscopic inguinal hernia repair with TAP (transversus abdominis plane) block as a day-case: A prospective cohort study

Totally extraperitoneal (TEP) endoscopic inguinal hernia repair is indicated for recurrent and bilateral inguinal hernias and traditionally is performed under general anesthesia. However, interventions that minimize pain and reduce opioid consumption have certain advantages for patients by avoiding side effects such as nausea and vomiting. The transversus abdominis plane (TAP) block has been used to minimize pain in a diverse range of surgical procedures but its safety on patients undergoing TEP repair has yet to be investigated. To assess the results of outpatient TEP repair with TAP block without curare. Consecutive patients undergoing elective TEP procedure were prospectively enrolled. Patients in two institutes received a similar anesthetic, surgical, and analgesic treatment protocol. Fifty consecutive day-case patients were included in this series. The TEP repair was successful in 49 patients and there was one conversion to transabdominal pre-peritoneal (TAPP) endoscopic inguinal hernia repair. The mean duration of surgery was 20min for unilateral hernia and 40min for bilateral hernia. These preliminary results suggest that day-case endoscopic hernia repair (TEP) with TAP block without curare is effective, safe, reproducible and can be proposed in all patients.

English

OBJECTIVES: To evaluate the safety and complications of the Laparoscopic Total Extra Peritoneal Procedure (LAP TEP) versus Lichtenstein's repair for Inguinal Hernia. Design: Prospective comparative study of 70 patients in the age group 18-80yrs with inguinal hernia. Setting: department of surgery, NKPSIMS & R.C. & Lata Mangeshkar Hospital, Hingna, Digdoh Hills, Nagpur from April 2012 to March 2014. Result: Mean age of patients in laparoscopy TEP repair were 49.40±17.88 & in open were 49.85±16.05 (p value 0.638). The mean time of surgery was higher in the laparoscopic group (1.42 ± 0.015) as compared to the open group (0.49 ± 0.01), this is due to the learning curve. A significant percentage of patients in the open group had fever due to wound infection this could be explained by the fact that most of the cases in the open group were done by residents. A higher incidence of cord edema was seen in the laparoscopic group (52%) as compared to the open group (11%), this may be due to the increased cord handling during the procedure. A higher incidence of haematoma was also seen in the laparoscopic group (20%) this again may be due to the learning curve and increased handling in the initial cases. Conclusion: laparoscopic hernia repair though being superior in terms of less pain and early return to active work is more expensive and requires specialised training. Laparoscopy is not a gold standard but in selected cases and in the hands of expert it is an excellent procedure.

Our experience with totally extraperitoneal technique of laparoscopic inguinal hernia repairs modified by Stolzenburg

Two current types of laparoscopic inguinal hernia repair are known: the TransAbdominal PrePeritoneal (TAPP) and the Totally ExtraPeritoneal (TEP) method. The mesh is placed in the preperitoneal space (sublay). Usually during TAPP method we fix the mesh with tacks or staples. In case of TEP fixation it is not necessary because the intraabdominal pressure keeps the implant in position. There is no significant difference between the two methods in terms of recurrence. The advantage of TEP is that the abdominal cavity remains intact, hence reduces the risk of intraabdominal injuries and adhesions. It is unnecessary to use special stapler or tacker. Our team performed 50 TEP procedures in male patients with uni- or bilateral inguinal hernias in the period 2011-2013. We prepared the mesh in a special way according to Stolzenburg and placed it to the subfunicular area. We did not apply additional fixation (tacks, stitches) and drainage. Mean hospital stay was 1 day. We allowed complete physical activity 10-12 days after surgery. No recurrence was observed during the 2 years of follow-up. The mean operating time was 70 minutes. We performed conversion in 3 cases (Lichtenstein 2, TAPP 1). In one case there was an injury of the inferior epigastric artery. In two cases we have detected neuralgia in the postoperative period. After the learning curve the TEP method can be used safely with good functional results. The technique of mesh positioning reduces the risk of complications and provides cost-effectiveness.

Single incision approach to totally extraperitoneal inguinal hernia repair.

IntroductionNowadays the vast majority of inguinal hernia repairs are laparoscopically assisted. Single incision laparoscopy aims to accelerate recovery and provide a better cosmetic outcome after the operation.AimTo present our own modification of the totally extraperitoneal (TEP) procedure with a single incision and without a multiport, and compare the results with those obtained in the classic three-trocar TEP method.Material and methodsThe study group comprised 61 males. The first group consisted of 35 males who underwent single incision videoscopic alloplasty TEP. The second group comprised 26 males who underwent videoscopic alloplasty using the classic approach. The study assessed the time of operation, complications and postoperative pain based on the VAPS scale.ResultsThe operation time in the first group was statistically longer compared with the time in the second group. The assessment of differences in postoperative pain in both the examined groups on the first and seventh day after the operation was considered statistically insignificant. In both the studied groups there was no recurrence of hernia established on the first and seventh day after the operation.ConclusionsThe reduced number of incisions in the TEP method with a single incision approach without a multiport involves a decrease in the number of postoperative scars, and thus offers a better cosmetic outcome compared with the classic TEP procedure. The time of TEP operation performed with a single incision approach without a multiport is statistically longer than the duration of the classic laparoscopic TEP procedure.

Trans‐Rectus Sheath Extra‐Peritoneal Procedure (TREPP) for Inguinal Hernia: The First 1,000 Patients

Introduction After the introduction of mesh in inguinal hernia repair, the focus to improve surgical technique has changed from recurrence to chronic postoperative inguinal pain. At present, the most common surgical techniques are the Lichtenstein hernioplasty and total extraperitoneal procedure. Both techniques have their own specific disadvantages, with regard to potential nerve damage and the necessity of general anesthesia, respectively.

How to perform an extracorporeal ductus deferens anastomosis without conversion to open inguinal hernioplasty in total extraperitoneal procedure

ANZ Journal of SurgeryVolume 84, Issue 3 p. 197-197 LETTER TO THE EDITOR How to perform an extracorporeal ductus deferens anastomosis without conversion to open inguinal hernioplasty in total extraperitoneal procedure Selim Birol MD, Selim Birol MD General Surgery, Maltepe C.I.K State Hospital, Istanbul, TurkeySearch for more papers by this authorAhmet Bekin MD, Ahmet Bekin MD General Surgery, Maltepe C.I.K State Hospital, Istanbul, TurkeySearch for more papers by this author Selim Birol MD, Selim Birol MD General Surgery, Maltepe C.I.K State Hospital, Istanbul, TurkeySearch for more papers by this authorAhmet Bekin MD, Ahmet Bekin MD General Surgery, Maltepe C.I.K State Hospital, Istanbul, TurkeySearch for more papers by this author First published: 04 March 2014 https://doi.org/10.1111/ans.12451Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume84, Issue3March 2014Pages 197-197 RelatedInformation

Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) for Inguinal Hernia: The First 1,000 Patients

After the introduction of mesh in inguinal hernia repair, the focus to improve surgical technique has changed from recurrence to chronic postoperative inguinal pain. At present, the most common surgical techniques are the Lichtenstein hernioplasty and total extraperitoneal procedure. Both techniques have their own specific disadvantages, with regard to potential nerve damage and the necessity of general anesthesia, respectively. The goal of this study was to evaluate the results of a new technique in which the inguinal nerves are not at risk, and in which general anesthesia is not needed: trans rectus sheath extraperitoneal procedure (TREPP). Between 2006 and 2010, a total of 1,000 patients were treated for inguinal hernia with TREPP. A questionnaire concerning pain, sensibility changes, patient satisfaction, and recurrence was sent to all patients. The questionnaire was completed by 932 patients. Almost 90% of patients had not experienced any pain since the surgical procedure; 8% of patients reported experiencing some pain, but less than preoperatively; and 2% of patients reported an increase in pain postoperatively. Recurrence occurred in 1 and 3% were unsure about this. Reduced sensibility of the scar, scrotum, and upper leg was reported by 12.4, 1.4, and 1.5%, respectively. Overall, 97.4% of patients were satisfied with the results of the surgical procedure. The time period in which TREPP was performed was not associated with any of the outcome measures. TREPP has proven to be a feasible new technique for inguinal hernia repair, with excellent results, justifying a randomized controlled trial in which TREPP should be compared with standard techniques.

Effective rectus sheath canal: does it affect total extraperitoneal approach for inguinal mesh hernioplasty?

Objectives: This study aimed to compare the effects of the 1st port placement at two different levels below umbilicus during the total extraperitoneal (TEP) laparoscopic repair of inguinal hernia and to check the hypothesis that shorter effective rectus sheath canal would facilitate the TEP procedure. Methods: Eighteen adult males underwent TEP repair for uncomplicated primary inguinal hernia in one year. First (optical) port was placed 1 cm and 2.5 cm below the umblicus in the two groups (I and II, respectively). Effective rectus sheath canal (ERSC) was measured. Primary outcome measures (endoscopic vision, ease of the procedure and operating time) were compared between the two groups. Results: ERSC (mean ± SD) was found 3.24 ± 0.41 and 2.08 ± 0.27 cm in group I (n = 7) and group II (n = 11), respectively (P < 0.05). Endoscopic vision was found significantly better in group II compared to group I; visual analogue score (VAS) 8.82 ± 0.41 vs 4.57 ± 0.45, respectively (P < 0.05). Procedure was found significantly easier in group II compared to group I (VAS 8.91 ± 0.44 vs 5.5 ± 0.65; P < 0.05). Operating time was found significantly lower in group II compared to group I (1.83 ± 0.3 vs 2.71 ± 0.42 h; P < 0.05). Conclusions: Shorter effective rectus sheath canal of ≤ 2 cm greatly facilitates the TEP hernioplasty in terms of endoscopic vision, ease of the procedure and operating time, and is highly recommended, especially for the beginners.

Is there an end of the “learning curve” of endoscopic totally extraperitoneal (TEP) hernia repair?

An important challenge of totally extraperitoneal (TEP) hernia repair is the learning curve. The European guidelines suggest that the learning curve ranges between 50 and 100 procedures, with the first 30-50 being critical. Others suggest that optimal outcomes are achieved after 200 or more TEP procedures. All TEP repairs performed between 2005 and 2009 were included in this study. The effect of (surgeon) expertise on perioperative complications, conversion to open anterior repair, and operative time was assessed to evaluate the extent of the learning curve of TEP repair. Intraoperative complications occurred in <1 % of the 3,432 patients and postoperative complications were observed in 243 (7 %) patients. With a median follow-up of 2 years after TEP, 19 patients (0.55 %) had a recurrence. During the study period, at the end of which all four surgeons had treated 900-1,000 patients, intraoperative complications and recurrences did not decline. On the other hand, the median operative time decreased from 30 to 20 min (p < 0.001). The conversion rate (1.6-0.2 %, p = 0.018) and postoperative complication rate (11.6-4.2 %, p < 0.001) also declined. The decline was observed for all four surgeons, irrespective of their initial expertise with TEP. The largest decrease in the conversion rate was seen after at least 250 TEP procedures; the postoperative complication rate and operative time showed a linear and significant decline throughout the study period. A more or less "steady state" was observed after approximately 450 procedures per surgeon. Even after more than 400 individually performed TEP procedures, there is progress in reducing the conversion rate, the incidence of short-term postoperative complications, and operative time, indicating a rather long learning curve.

The effect of ultrapro or prolene mesh on postoperative pain and well-being following endoscopic Totally Extraperitoneal (TEP) hernia repair (TULP): study protocol for a randomized controlled trial

BackgroundThe purpose of this study was to describe the rationale and design of a randomized controlled trial analyzing the effects of mesh type (Ultrapro versus Prolene mesh) on postoperative pain and well-being following an endoscopic Totally Extraperitoneal (TEP) repair for inguinal hernias (short: TULP trial).Methods and designThe TULP trial is a prospective, two arm, double blind, randomized controlled trial to assess chronic postoperative pain and quality of life following implantation of a lightweight (Ultrapro) and heavyweight (Prolene) mesh in endoscopic TEP hernia repair. The setting is a high-volume single center hospital, specializing in TEP hernia repair. All patients are operated on by one of four surgeons. Adult male patients (≥18 years of age) with primary, reducible, unilateral inguinal hernias and no contraindications for TEP repair are eligible for inclusion in the study. The primary outcome is substantial chronic postoperative pain, defined as moderate to severe pain persisting ≥ 3 months postoperatively (Numerical Rating Scale, NRS 4–10). Secondary endpoints are the individual development of pain until three years after the TEP procedure, the quality of life (QoL), recurrence rate, patient satisfaction and complications.DiscussionLarge prospective randomized controlled studies with a long follow-up evaluating the incidence of chronic postoperative pain following implantation of lightweight and heavyweight mesh in endoscopic (TEP) hernia repair are limited. By studying the presence of pain and quality of life, but also complications and recurrences in a large patient population, a complete efficiency and feasibility assessment of both mesh types in TEP hernia repair will be performed.Trial registrationThe TULP study is registered in the Dutch Trial Register (NTR2131)

A comparative study of standard versus laparoendoscopic single-site surgery (LESS) totally extraperitoneal (TEP) inguinal hernia repair

Laparoscopic inguinal hernia repair has been around since the 1990s. A novel surgical approach known as laparoendoscopic single-site surgery (LESS) has been developed to reduce the port-related morbidities and improve the cosmetic outcomes of laparoscopic surgery, including totally extraperitoneal (TEP) inguinal hernia repair. The aim of the present study was to evaluate the safety and feasibility of the LESS TEP technique for inguinal hernia repair and compare the outcomes with the standard TEP approach. Between January and May 2009, 54 consecutive healthy patients (48 men and 6 women) underwent LESS TEP inguinal hernia repair at our institute. All procedures were performed using our homemade single port for simultaneous passage of the laparoscope and instruments. The perioperative data, including patient age, sex, body mass index (BMI), hernia characteristics, operative time, complications, length of hospital stay, return to normal activity, pain score, and cosmetic result, were prospectively collected. All LESS TEP procedures were completed successfully without conversion to standard laparoscopic or open surgery. A total of 98 LESS TEP hernia repairs were performed in 54 patients and compared with 152 standard TEP operations. The mean operative time was significantly shorter in the standard TEP series (61.8±26.0 vs. 70.9±23.8min, p=0.04). Other perioperative parameters, including the length of hospital stay, time until return to full activity, complication rate, pain score, and cosmetic result, were all comparable between the two techniques. Our short-term experience with LESS TEP inguinal hernia repair has shown that in experienced hands, inguinal hernia repair via the LESS TEP technique is as safe as the standard TEP technique. However, based on our evidence, we currently believe that the LESS TEP technique is not an efficacious surgical alternative to the standard TEP technique for inguinal hernias.

Bilateral inguinal hernia repair: laparoscopic or open approach?

The aim of this study was to investigate outcomes in the treatment of bilateral inguinal hernia, comparing the laparoscopic totally extraperitoneal (TEP) and open tension-free mesh repair (LICHT) approaches. We performed a prospective controlled non randomized clinical study in 128 patients with bilateral inguinal hernia over a period of 3 years. LICHT was used in 106 cases (53 patients) while TEP was employed in 150 cases (75 patients). The main outcome measurements were: recurrence rate, operating time, hospital stay and postoperative complications. There were three recurrences (2.3%): two in the LICHT group (3.8%) and one (1.3%) in the TEP group P = NS. The TEP procedure was faster than LICHT repair (48.8 ± 10.8 vs. 70.4 ± 11.2 min) P < 0.01. Postoperative complications were more frequent in LICHT group (16%) than TEP group (5.3%) P < 0.01. Hospital stay was significantly shorter in the TEP group (0.6 ± 0.8 vs. 1.3 ± 1.2 days) P < 0.001. The TEP approach is an effective option for the treatment of bilateral inguinal hernia when performed by experienced surgeons.

Femoral vessel blood flow dynamics following totally extraperitoneal vs Stoppa procedure in bilateral inguinal hernias

Background Both totally extraperitoneal (TEP) and open preperitoneal (Stoppa) procedures involve the placement of prosthetic material preperitoneally. Because the prosthetic material overlies the femoral artery and vein, the aim of this study was to assess its effect on the velocities and diameters of the artery and vein using color Doppler ultrasonography in both approaches. Methods Sixty-four patients with bilateral groin hernias were prospectively randomized to undergo either TEP (n = 32) or Stoppa (n = 32) repair. All patients underwent color Doppler ultrasound 6 months after the procedures, and the median follow-up period was 18 months. Results Neither mean diameter nor mean flow velocity was changed by the insertion of the mesh preperitoneally. The only change was observed in peak systolic femoral arterial blood velocity, which was significantly decreased in the Stoppa group. Also, no patient in this study developed clinically significant deep venous thrombosis during 6 months of follow-up. Conclusions The insertion of a prosthetic mesh during TEP and Stoppa procedures does not influence the mean peak flow velocities and cross-sectional areas of the vessels in the inguinal region and can be used safely for open and laparoscopic preperitoneal approaches.

The preperitoneal loop in inguinal hernia repair following the totally extraperitoneal technique

With increasing experience in totally extraperitoneal (TEP) hernia repair, we observed an anatomical structure not described in the literature. It is a loop-like structure under the ductus deferens or ligamentum teres uteri anchored laterally and medially to the peritoneum. Relatively constant in distance to the inner inguinal ring and individual in the grade of prominence, it inhibits correct patch placement medially. To identify and describe this so-called preperitoneal loop (pl), we performed this study. Between February 2nd and July 15th 2006, all patients undergoing a TEP procedure at our institution in primary inguinal hernia without previous operations in the lower abdomen were included. The main topic was the prominence and distance to the inner inguinal ring of the pl and histological examinations were made. A total of 219 patients (194 male, 25 female) were included, with 97 right-side, 64 left-side and 58 bilateral hernias. The pl could be shown in 206 cases (94%), the distance to the inner ring was up to 1.5 cm in 60, between 1.5 and 3.0 cm in 112, and over 3 cm in 34 cases. Anatomical examinations showed smaller blood vessels embedded in fatty tissue and surrounded by collagen fibres (standard haematoxylin eosin [HE]) and collagen connective tissue strongly filled with elastic fibres and, occasionally, nerve fibres and lymphatic capillaries (van Gieson). The pl is a very constant structure that is independent of gender and hernia type and size. In most cases, it is found close to the inner inguinal ring and, therefore, has to be cut for adequate parietalisation of cord structures/ligamentum teres uteri and correct mesh placement medially. As no mesothel was found, the origin of pl might be the deeper sheet of transversalis fascia.

Commentary on: T. Sinnett, N. Karanjia (2009) Decompression of a pneumoperitoneum during a total extraperitoneal (TEP) inguinal hernia repair by incision of the umbilical sac under direct vision

Since total extraperitoneal (TEP) hernia repair was introduced in the early 1990s, there has been associated discussion regarding pneumoperitoneum. If the latter occurs, and this is not a rare event, the extraperitoneal space can become smaller. This can of course seriously interfere with the TEP procedure and in some cases can necessitate conversion to transabdominal preperitoneal (TAPP) or conventional hernia repair, especially in the early stages of the learning curve. As a solution to this problem many surgeons use a Verres needle for decompression of the peritoneal space. As Sinnett mentions in his letter to the editor, this method encompasses all the disadvantages and risks of blind peritoneal puncture. In addition, a Verres needle has a maximum flow rate of 2 l/min. So decompression takes time, or is impossible or unsatisfactory due to the much higher flow rate of any working trocar. Thus, according to in our experience, following a few unsuccessful attempts in 1994, we have never considered a Verres needle as the solution to the problems of pneumoperitoneum. Sinnett now mentions a new method of decompression by umbilical opening of the peritoneal sac. This of course seems to be safe, and probably gives rise to a better flow. However, due to surface tension, the smaller bubble (extraperitoneal space) will always blow up the bigger one (intraperitoneal space). Thus, in my mind, and in our experience, decompression of the intraperitoneal space does not provide a routine solution to the problem of peritoneal tears in TEP (in our hands close to 50% of procedures). We use a different procedure and, since we started with TEP, up to now we have never had a conversion due to pneumoperitoneum in more than 8,000 cases in two different clinics:

A Randomized Control Trial of Levobupivacaine, Bupivacaine Versus Placebo Extraperitoneal Infusion in Totally Extraperitoneal Laparoscopic Inguinal Hernioplasty

Totally extraperitoneal (TEP) laparoscopic inguinal hernioplasty procedure is significantly less painful than open repair, but it is not completely painless. The aim of this study was to compare the effect of extraperitoneal infusion of 0.25% levobupivacaine, 0.25% bupivacaine, and placebo in patients undergoing TEP procedure in terms of pain reduction. Twenty patients were included in each group for TEP procedure. Group A received 40 mL of 0.9% normal saline, group B received 40 mL of 0.25% bupivacaine, and group C received 40 mL of 0.25% levobupivacaine infused into the extraperitoneal space before closing. Postoperative pain was assessed at 4, 8, 12, 24, 36, and 48 h postoperatively. Analgesic requirement, complications, and overall satisfaction were also recorded. The demographic and surgical characteristics of the patients did not significantly differ among groups. There were no statistical differences among groups in postoperative pain scores, total IV-PCA morphine requirement, complications, and overall satisfaction. Extraperitoneal infusion 40 mL of 0.25% bupivacaine or 0.25% levobupivacaine following TEP procedure did not show any benefit over placebo in terms of pain reduction.

Feasibility of right-sided total extraperitoneal procedure for inguinal hernia repair after appendectomy: a prospective cohort study

BackgroundTotally extraperitoneal (TEP) endoscopic hernia surgery is increasingly popular since it is associated with little postoperative pain and with early return to work. Previous appendectomy may preclude preperitoneal dissection in patients with right-sided hernias. The feasibility of TEP surgery in these patients was the subject of the present study.MethodsBetween January 2005 and February 2007 all consecutive patients undergoing TEP surgery were included in a prospective cohort study. The study group consisted of patients with right-sided and bilateral hernias. Operative times, conversions, complication rates, and return to daily activities were recorded. Patients were divided into two groups according to previous appendectomy.ResultsA total of 462 patients with right-sided hernias underwent TEP surgery: 421 patients without previous abdominal surgery (group 1) and 41 patients with previous appendectomy (group 2). The conversion rate was significantly higher in group 2: four patients (10%) were converted to open Lichtenstein repair versus five (1%) in group 1 (p = 0.005). However, we found no significant differences in complication rate, operative time, and return to daily activities.ConclusionsA right-sided (or bilateral) TEP procedure may be performed safely in patients after previous appendectomy. Despite a higher conversion rate, the vast majority of patients can be operated endoscopically.

Laparoscopic Totally Extraperitoneal Hernia Repair Versus Open Lichtenstein Hernia Repair: Results and Complications

Whereas open Lichtenstein inguinal herniorrhaphy is generally accepted as a safe, well-understood method with a high success rate, the laparoscopic repair of a inguinal hernia is a fairly recent technique. Although the laparoscopic approach to a hernia repair procedure is associated with less pain and faster recovery than open repair, many surgeons are not familiar with this technique owing to technical demands and a long learning curve. This study compares the results and complications between open tension-free mesh (Lichtenstein) repair and laparoscopic total extraperitoneal (TEP) repair. The study cohort was comprised of 345 consecutive patients who underwent an inguinal herniorraphy procedure. An open hernia repair was performed on one group of patients (n = 233), whereas TEP repair was performed on the other (n = 112), and then the comparison of intra- and postoperative complications and results obtained from both techniques was done. The mean hospital stay was similar in both groups. The average operative time in the TEP group was 58.6 +/- 18.1 minutes, and the average operative time in the open group was 58.2 +/- 17.8 minutes. There was no difference in postoperative complication rates between the two groups, except for urinary retention, which patients who underwent TEP repair were more likely to get. The following major complications were recorded: 2 cases of urinary bladder perforation-1 during TEP repair and the other during Lichtenstein repair, but both with good postoperative outcome-and 1 case of pneumothorax, which occurred during the TEP procedure. Despite the fact that TEP is a demanding procedure, it may be performed efficiently with an acceptable operating time and a low complication rate.

Managing intra-operative complications during totally extraperitoneal repair of inguinal hernia

Laparoscopic inguinal hernia repairs are looked upon as technically demanding procedures having have a stiff 'learning curve' associated with its performance in terms of clinical outcome and patient's satisfaction. Complication rates have been shown to drop with increased surgical experience. The complication rate for laparoscopic repair of inguinal hernia ranges from less than 3% to as high as 20%. Complications of a totally extraperitoneal (TEP) repair include general complications that occur with any surgical procedure and anesthesia, mesh-related complications and those specific to the TEP procedure, like visceral injury, vascular injury, nerve injury and injury to the cord. Intraoperative complications can occur at every step of the operation, even though some of them are only occasionally reported. However, it is important to analyze all of them chronologically, so that we can define methods to prevent them or tackle them if they occur. Risk reduction strategies are required to improve the clinical outcome of TEP and this must be adopted for each individual surgical step.