Total Extraperitoneal Herniorrhaphy Research Articles

Analysis of recurrent factors and therapeutic effect after laparoscopic inguinal hernia repair

Objective: To analyze the recurrence factors and reoperation effect of laparoscopic inguinal hernia repair. Methods: A total of 41 patients with recurrence after laparoscopic repair of the inguinal hernia admitted to the Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University from January 2017 to December 2021 were retrospectively analyzed. All patients were males, aging (62±7) years (range: 51 to 75 years). The recurrence intervals were 3 days to 7 years postoperatively. The surgical methods, causes of recurrence, and treatment outcomes of the patients were analyzed. Fisher exact probability method is used to compare the rates. Results: Among all cases, the primary surgical procedures included transabdominal preperitoneal herniorrhaphy (TAPP) in 31 cases and total extraperitoneal herniorrhaphy in 10 cases. The reoperative procedures included the TAPP of 11 cases and the Lichtenstein procedure of 30 cases. The factors of recurrent cases in all patients could be divided into 4 categories, including insufficient mesh coverage in 23 cases, mesh curling in 9 cases, mesh contractuture in 7 cases, and improper mesh fixation in 2 cases. Recurrence, infection, chronic pain, foreign body sensation didn't occur in the followed period of(M(IQR)) 18(24) months(range: 12 to 50 months). There was no statistical difference in the incidence of postoperative seroma between the TAPP and Lichtenstein procedure (3/11 vs. 20.0% (6/30), P=0.68). Conclusions: Postoperative recurrence of laparoscopic inguinal hernia is mostly caused by the lack of mesh coverage. Due to the emphasis on standardized surgical operation, a good outcome could be achieved through reoperation by the TAPP or Lichtenstein procedure.

Laparoendoscopic Single-Site Inguinal Herniorrhaphy: Experience of a Single Institute

Background: Minimally invasive techniques for inguinal herniorrhaphy have focused on developing the laparoendoscopic single-site (LESS) procedure to improve cosmesis. Outcomes of total extraperitoneal (TEP) herniorrhaphy vary considerably because of being performed by different surgeons. We aimed to evaluate the perioperative characteristics and outcomes of patients undergoing the LESS-TEP approach for inguinal herniorrhaphy and to determine its overall safety and effectiveness. Methods: Data of 233 patients who underwent 288 laparoendoscopic single-site total extraperitoneal approach (LESS-TEP) herniorrhaphies at Kaohsiung Chang Gung Memorial Hospital between January 2014 and July 2021 were reviewed retrospectively. We reviewed the experiences and results of LESS-TEP herniorrhaphy performed by a single surgeon (CHC) using homemade glove access and standard laparoscopic instruments with a 50 cm long 30° telescope. Results: Among 233 patients, 178 patients had unilateral hernias and 55 patients had bilateral hernias. About 32% (n = 57) of patients in the unilateral group and 29% (n = 16) of patients in the bilateral group were obese (body mass index ≥ 25). The mean operative time was 66 min for the unilateral group and 100 min for the bilateral group. Postoperative complications occurred in 27 (11%) cases, which were minor morbidities except for one mesh infection. Three (1.2%) cases were converted to open surgery. Comparison of the variables between obese and non-obese patients found no significant differences in operative times or postoperative complications. Conclusion: LESS-TEP herniorrhaphy is a safe and feasible operation with excellent cosmetic results and a low rate of complication, even in obese patients. Further large-scale prospective controlled studies and long-term analyses are needed to confirm these results.

The Learning Curve for Laparoscopic Totally Extraperitoneal Herniorrhaphy by Logarithmic Function: Consecutive 291 cases Performed by a Single Surgeon

Purpose: The Totally extraperitoneal (TEP) herniorrhaphy is not an easy technique for beginner surgeons because of the complexity of inguinal anatomy and narrow space of the operation field. The aim of this study is to estimate learning curve of laparoscopic TEP herniorrhaphy using logarithmic function model and the exponential function model. Revealing the number of cases needs to overcoming the early learning curve and minimizing the recurrence rate.

Totally Extraperitoneal Herniorrhaphy (TEP): Lessons Learned from Anatomical Observations.

Background Totally extraperitoneal herniorrhaphy (TEP) is a therapeutic challenge because of its complex anatomical location in inguinal region. The aim of this study was to describe the related surgical anatomy through laparoscopic observation and share the lessons learned from a review of 250 primary inguinal hernia repair procedures performed at our hospital from January 2013 to November 2019. Patients and Methods. There were 245 men and 5 women (median age: 63.2 years). Right hernia (60.2%) was the most common site. Indirect hernia (60.5%) was the most common abnormality. The classification of type II (65.0%) was the most common form. Surgical techniques comprised retromuscular approach using cauterized dissection, management of variations of arcuate line, Retzius space and Bogros space dissection, hernia sac reduction, and mesh positioning. Results The incidence of peritoneum injury was in 27 (10.1%). No epigastric vessels were injured. There were 8 (3%) hematoma and 18 (6.8%) seroma. No mesh infection, chronic pain, and recurrence were found after follow-up of an average of 35 months. Conclusion A good understanding of the anatomically complex nature in the inguinal region can make it easier and safer to learn the TEP approach. Early and midterm outcomes after TEP are satisfactory.

Safety of two common laparoscopic inguinal herniorrhaphy approaches: an updated systematic review with meta-analysis of randomized clinical trials.

BackgroundPrevious evidence indicated that total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) are advantageous in efficacy of inguinal herniorrhaphy. Therefore, our aim in this study was to evaluate the association of the two laparoscopic approaches on safety of inguinal herniorrhaphy.MethodsIn this update study, we searched the Cochrane Library, EMBASE, PubMed, Scopus, and Web of Science and identified randomized clinical trials comparing complications in TEP and TAPP herniorrhaphy. We mainly used Peto odds ratio with 95% confidence interval (CI) for meta-analysis because of zero-cell.ResultsFourteen eligible trials recruited 659 and 682 patients in TEP and TAPP respectively. In overall pooling, although TEP had a higher seroma rate than TAPP (Peto odds ratio =2.01; 95% CI, 1.39 to 2.91), it had a lower scrotal/cord edema rates at immediate postoperative (Peto odds ratio =0.22; 95% CI, 0.09 to 0.57) and 1 week after inguinal hernia repair (Peto odds ratio =0.58; 95% CI, 0.37 to 0.91) than TAPP.ConclusionsTEP and TAPP have their own advantages in inguinal herniorrhaphy. TAPP was associated with a lower seroma rate, and TEP was associated with a lower edema rate. Therefore, shared decision-making on laparoscopic inguinal herniorrhaphy with TEP and TAPP is still needed.

What happens after no contralateral exploration in total extraperitoneal (TEP) herniorrhaphy of clinical unilateral inguinal hernias?

While performing unilateral TEP herniorrhaphy, controversy still exists about whether to do contralateral exploration or not. Routine contralateral exploration has been proposed to prevent metachronous contralateral hernias by the repair of incidental contralateral occult hernias. Some surgeons have even proposed to do prophylactic bilateral TEP herniorrhaphy for unilateral hernia patients. To evaluate the appropriateness of not doing contralateral exploration in unilateral TEP herniorrhaphy, we reviewed our experiences under our practice of no contralateral exploration and we also reviewed other published literature. A total of 305 patients who underwent 313 TEP herniorrhaphies for inguinal hernias by a single surgeon during August 2012-July 2016 at Chia-Yi Christian Hospital were enrolled in this retrospective study. Demographic, perioperative and follow-up data were obtained for analysis and review. Of the 305 patients, 261 patients had unilateral TEP herniorrhaphy and 44 patients had bilateral TEP herniorrhaphy. The mean operation time for the unilateral TEP herniorrhaphy group was 59.8min, and for the bilateral TEP herniorrhaphy group it was 85.2min (p<0.001). Seven of 261 (2.7%) patients had metachronous contralateral hernia after unilateral TEP herniorrhaphy. There were no statistically significant differences in any of the outcome variables when comparing the sequential and simultaneous primary bilateral TEP herniorrhaphies. Without routine contralateral exploration, the incidence of metachronous contralateral hernia was 2.7% (7/261) in unilateral hernia patients. This is acceptable as metachronous hernia also occurred in 3.2% of patients with negative contralateral exploration according to our literature review. Sequential and simultaneous bilateral primary TEP herniorrhaphy outcomes were similar. We conclude that no exploration for the other groin is a justified decision for unilateral inguinal hernia patients.

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.

An experience with self-maid modified surgipro mesh for laparoscopic total extraperitoneal herniorrhaphy

An experience with self-maid modified surgipro mesh for laparoscopic total extraperitoneal herniorrhaphy

Totally Extraperitoneal Herniorrhaphy (TEP) after Ipsilateral Spermatic Vein Embolization: A Case Report

Introduction: Both totally extraperitoneal herniorrhaphy (TEP) and spermatic vein embolization are minimal invasive techniques gaining in popularity in the treatment of inguinal hernia and varicocele respectively. A previous spermatic vein embolization makes a TEP more difficult because of fibrotic changes of the spermatic vein. This is to our knowledge the first case report describing these difficulties and changes after spermatic vein embolization. Case Presentation: We report the case of a 37 year old male who presented with an uncomplicated left sided inguinal hernia and ipsilateral varicocele. He first underwent a percutaneous left spermatic vein embolization for a grade 3 varicocele and later a TEP for the inguinal hernia. Reduction of the peritoneum and proper mesh placement were complicated due to fibrotic changes of the spermatic vein. Due to the dissection and resection of the embolized spermatic vein there was minor blood loss, increased operating room time and postoperative pain was more then average. Conclusions: In case of a concomitant inguinal hernia and ipsilateral varicocele requiring embolization we propose to treat these diseases concomitantly or first treat the inguinal hernia and embolising the varicocele after repair of the hernia.

Efficacy and outcome of total extraperitoneal herniorrhaphy (TEP) in patients with recurrent inguinal hernia

Efficacy and outcome of total extraperitoneal herniorrhaphy (TEP) in patients with recurrent inguinal hernia

Clinical evaluation of a novel commercial single port in laparoendoscopic single-site surgery

IntroductionEndoscopic total extraperitoneal herniorrhaphy (TEP) has emerged as a recognized surgical method for adult inguinal hernia. To reduce port-site-related morbidity and improve postoperative convalescence, a novel surgical approach known as laparoendoscopic single-site surgery (LESS) TEP repair has been developed. AimTo compare the clinical efficiency of a novel commercial single port with a homemade single port in TEP groin hernia repair. MethodsSixty consecutive patients undergoing LESS TEP repair were enrolled in this trial with 31 in the homemade port group and 29 in the commercial single-port group. Preoperative, intraoperative, and postoperative factors were recorded. The patients were interviewed postoperatively at outpatient clinics. ResultsThe demographic data were comparable between the two groups. The median operative time was longer in the homemade port group than in the commercial port group (59.4 vs. 51.4 minutes, respectively, p = 0.04). The homemade port group was significantly associated with more port-related malfunctions than the commercial port group (19% vs. 0, respectively, p = 0.02). The postoperative results were comparable between the groups in pain scores, analgesic requirements, complications, and postoperative convalescence. ConclusionThe novel commercial single port studied is associated with less intraoperative malfunctions and improved the procedural efficiency of LESS TEP for groin hernia repair. Thus, a well-designed commercial port will be of significant benefit in overcoming the existing procedural inefficiencies of single-port surgery performed using a homemade port, which requires relatively time-consuming procedures and significant experience of the surgeon.

The use of porcine small intestine submucosa implants might be associated with a high recurrence rate following laparoscopic herniorrhaphy

The efficacy of porcine small intestine submucosa (SIS) implants in hernia repair has rarely been reported and remained elusive. We herein report our experience to further elucidate the efficacy of SIS mesh in herniorrhaphy. Between June 2008 and October 2009, a total of 82 patients with 125 inguinal hernias undergoing endoscopic total extraperitoneal (TEP) herniorrhaphy were included. Seventy patients (with 108 hernias) had traditional polypropylene and 12 patients (with 17 hernias) had SIS mesh repair. Postoperative complications and recurrence rates were compared between the two meshes. The demographics between two groups were similar. All operations were performed smoothly with laparoscopy, and the postoperative courses were uneventful. After a median follow-up of 18 months, five (7%) in the polypropylene group and three (25%) in the SIS group had chronic pain (p=0.09). Five of 17 (29.4%) hernia repairs in the SIS group had an ipsilateral recurrence, compared to no recurrence in the polypropylene group. In the five cases, the second laparoscopy revealed the SIS mesh had been totally degraded and there was no obvious fibrotic tissue in the previous mesh sites. Our data suggest that the use of SIS mesh in endoscopic TEP herniorrhaphy might be associated with a high recurrence rate. The second look laparoscopy in these recurrent cases revealed slow and inadequate integration of host tissue. More evidence is still required to further evaluate the efficacy of SIS mesh in endoscopic TEP herniorrhaphy.

A rare complication from total extraperitoneal (TEP) laparoscopic inguinal hernia repair: bladder rupture associated with a balloon dissector

We report a rare complication of TEP herniorrhaphy. A 47-year-old man underwent TEP inguinal hernia repair. Bladder rupture was noted after balloon dissection. The defect was sutured, and the hernia was repaired under laparoscopy. Cystoscopy showed the site of injury at anterior bladder neck. This is the first report of bladder rupture associated with balloon dissector in a patient with no prior abdominal surgery.

Synchronous Cholecystectomy and Totally Extraperitoneal (TEP) Herniorrhaphy Using an Umbilical Incision

Two or more procedures maybe combined into a single surgical event using an abdominal laparoscopic surgery technique. Synchronous operations can provide patients with the advantage of a single hospital stay, single anesthetic exposure and single recovery period. Cholecystectomy and totally extraperitoneal (TEP) herniorrhaphy should be performed in both extremities and in different spaces of the abdomen. As described in this report, laparoendoscopic single site surgery (LESS), synchronous cholecystectomy and TEP herniorrhaphy were successfully performed using an umbilical incision in a single surgical event.

The learning curve for laparoscopic totally extraperitoneal herniorrhaphy by moving average

PurposeLaparoscopic totally extraperitoneal (TEP) herniorrhaphy has been recognized as a treatment option for inguinal hernia. The objective of this study was to clarify the learning curve for laparoscopic TEP herniorrhaphy using the moving average method.MethodsA total of 90 patients underwent laparoscopic TEP herniorrhaphy by a single surgeon between March 2009 and March 2011. We analyzed medical records including the demographic data, operating time, hospital stay, and postoperative complications.ResultsThe mean operating time of the initial 30 cases (learning period group) was 66.3 minutes. After the initial 30 cases were performed, the time decreased to 52.8 minutes in the later 60 cases (experienced period group, P = 0.015). This represents the operating time becoming stabilized and then decreasing as the number of performed cases accumulates. Hospital stay was shorter and frequency of pain control, and complication rate were lower in the experienced period, however, there was no statistical significance.ConclusionWe suggest that number of patients needed for the learning curve for laparoscopic TEP herniorrhaphy should be 30 cases. The operating time for laparoscopic TEP herniorrhaphy stabilizes after 40 cases in moving average analysis.

Laparoscopic Extraperitoneal Resection of Urachal Cyst

Remnant urachal cyst is a rare anomaly with an incidence of 1 : 5,000 and the majority are benign. The treatment of urachal cyst is complete surgical resection, and the cases of laparoscopic surgery for the resection have been reported since 1993. Most of the reports were about transabdominal laparoscopic approach, and it has been revealed that multiple skin incisions and trocar placements on upper abdomen were ineludible. With this condition, we are able to describe an extraperitoneal approach modified from total extraperitoneal herniorrhaphy, and to report a case of successful management of a urachal cyst by total extraperitoneal laparoscopic excision.

The Feasibility of Laparoscopic Total Extraperitoneal (TEP) Herniorrhaphy after Previous Lower Abdominal Surgery

Purpose: We retrospectively reviewed the medical records to estimate the feasibility and surgical outcome of laparoscopic herniorrhaphies in patients with previous lower abdominal surgery. Methods: Between December 2000 and December 2008, a total of 1,101 cases of laparoscopic herniorrhaphies were performed in 974 patients, among them 47 cases (4.27%) of laparoscopic herniorrhaphy in 40 patients who had undergone previous lower abdominal surgery were enrolled to this study. Results: Most patients (23 of 24) who had a history of appendectomy successfully underwent laparoscopic totally extraperitoneal (TEP) repair. Six patients who had history of a prostatectomy and 2 patients with a Pfannenstiel incision underwent an intraperitoneal only mesh (IPOM) repair after a failed TEP repair. Five patients had lower midline incisions due to panperitonitis, among them TEP repairs were performed in 3 patients and IPOM was performed after failed TEP repairs in 2 patients who had undergone surgery due to trauma-induced rupture of the bladder. Conclusion: Laparoscopic TEP hernia repair could be possible and reasonable in patients after an appendectomy; however, it is difficult in patients with previous pelvic surgeries. Additional studies are needed to determine whether or not laparoscopic TEP repair for inguinal hernias is feasible in patients who have undergone other general surgical procedures.

Traditional polypropylene and lightweight meshes in totally extraperitoneal inguinal herniorrhaphy

Background Placement of a prosthetic mesh is integral to successful totally extraperitoneal (TEP) herniorrhaphy. Available meshes have supported the surgical efforts well but search for an ideal mesh continues. Post-herniorrhaphy pain is an index of patient reported outcomes (PRO). The pain is attributable to balloon dissection, cautery, sutures, tackers and prosthesis. Reducing polypropylene content of the mesh is associated with attenuated inflammatory response by the host and improved compliance and comfort. We report the difference in PROs in TEP herniorrhaphy with either heavy polypropylene (PPM) or light weight mesh (LWM) being used for the repair. Patients and methods From June 2004 to December 2005, consecutive candidates for TEP herniorrhaphy were enrolled for this prospective study with an informed consent and compliance to Ethics guidelines. They were operated under general anesthesia (GA) on a day care basis using either PPM or LWM meshes as per the patient's choice. Operative and postoperative PRO were statistically analyzed by an independent doctor using the Microsoft Office Excel 2003. Results One hundred fourteen (84 PPMs and 30 LWMs) TEP herniorrhaphies were performed under GA on 57 male patients without any exclusion, on a day care basis. There was no technical difficulty, operative complications, conversion or prolonged hospital stay in either group. Patients of LWM reported better outcome in regards to pain, NSAID usage, seroma and recurrence. All patients of LWM reported an earlier return to activity. Conclusion Light weight meshes result in comparatively better “patient reported outcomes” in TEP inguinal herniorrhaphy as compared to heavy polypropylene meshes.

Prospective double-blind randomized controlled study comparing heavy- and lightweight polypropylene mesh in totally extraperitoneal repair of inguinal hernia: early results

Success of totally extraperitoneal (TEP) inguinal herniorrhaphy depends upon strengthening of the weakened native tissue by inflammation resulting in mesh-aponeurosis scar tissue (MAST) complex formation. The inflammatory response attributable to polypropylene (PP) content of the mesh is linked to weight of PP and pore size of the mesh. Continuation of the inflammatory process beyond MAST complex formation can entrap contiguous structures, leading to adverse outcome such as groin pain. Reduction of PP content has been shown to be beneficial in animal studies. Paucity of randomized controlled trials (RCTs) on human beings has left choice of mesh to surgeon preference or cost. We carried out a double-blind RCT comparing heavy- and lightweight PP-based meshes in TEP. Consecutive, married, sexually active male candidates for bilateral TEP herniorrhaphy were enrolled without any exclusion, with ethical and informed consent protocol. Standard TEP technique was followed for day-care surgery. Heavy- and lightweight meshes were implanted in each patient, one in either groin after randomization. Surgeon and patient were blinded to side of groin and type of mesh. An independent doctor (AID) evaluated the patients for groin pain, discomfort, sexual dysfunction, and clinical recurrence. A nonmedical secretary/AID transferred prospective data for both sides of groin collected by AID to Microsoft Excel. Twenty-five bilateral TEPs implanting 25 heavy- and 25 lightweight PP meshes, one of each type in each patient, were performed from December 2005 to July 2007 without difficulty or complication. Lightweight PP mesh was associated with significantly better pain scores, patient comfort, and sexual function. There was no infection or recurrence with either type of mesh. Lightweight PP mesh is associated with significantly better outcomes in TEP inguinal herniorrhaphy as compared with heavyweight PP mesh.

Cost containment and totally extraperitoneal laparoscopic herniorrhaphy.

Surgeons who favor the laparoscopic repair of groin hernias are under pressure to contain the additional hospital costs associated with this technique, which is not universally acknowledged to be superior to less expensive open repairs. The purpose of this study was to compare costs and quality for TEP (total extraperitoneal) herniorrhaphy performed with and without balloon dissection and disposable cannulas. We studied 92 TEP patients. The first 36 patients (group 1) were repaired using balloon dissection and disposable cannulas. The next 37 patients (group 2) were repaired with nondisposable access cannulas, without balloon dissection and with disposable working ports. The final 19 patients (group 3) were repaired just as in group 2 except that all cannulas were nondisposable. The demographic data and complications were comparable for all three groups. The average hospital cost per case for group 1 procedures was $2,099; for group 2, it was $1,920; and for group 3, it was $1,607. Costs for patients decreased comparably but for different reasons. Also reviewed were 20 patients who underwent Lichtenstein repairs during the study period. The average hospital cost for these repairs was $1,556. This group was not randomized with TEP groups, and the selection criteria were different; hence, data comparing the Lichtenstein and TEP procedures were not analyzed statistically. Costs can be significantly reduced and quality maintained when performing TEP herniorrhaphy without balloon dissection using nondisposable cannulas.