Total Extraperitoneal Inguinal Hernia Repair Research Articles

Randomized Comparative Study Between Laparoscopic Transabdominal Pre-Peritoneal Versus Totally Extraperitoneal Approach in Inguinal Hernia Repair

Background: Whether totally extraperitoneal inguinal hernia repair (TEP) is associated with better outcomes than transabdominal preperitoneal inguinal hernia repair (TAPP) continues to be a matter of debate. The objective of this study is to compare outcomes between patients undergoing TEP or TAPP. Methods: This prospective randomized comparative study was carried out in Gastrointestinal and Laparoscopic Surgery Unit, General Surgery Department, Tanta University Hospitals from May 2016 to May 2017, on 30 patients with inguinal hernia, divided into 2 equal groups: Group I: subjected to Transabdominal Pre-peritoneal (TAPP) inguinal hernia repair (15 cases). Group II: subjected to Totally Extraperitoneal (TEP) inguinal hernia repair (15 cases). Results: The mean age was 47.8±10.4 ranged from 19-65 years. All patients were presented with indirect inguinal hernia. All cases were male except one female patient. Operative time was 151.7±24.8 in TAPP approach in comparison to 88.42±30.6 minutes in TEP approach. Post-operative scrotal edema was higher in TAPP approach (9 cases) in comparison to TEP approach (3cases). Postoperative Hematoma and ileus were higher in TAPP technique (2cases). Postoperative Surgical emphysema was higher in TEP technique (3cases). Hospital stay in TAPP approach was longer than TEP approach. There was no difference regarding wound infection, mesh infection and recurrence. Follow up for 6 months of all cases for complication. Conclusion: TEP approach as the laparoscopic procedure of choice for inguinal hernia repair due to short operative time and less hospital stay than TAPP approach.

Evaluation of short-term outcomes of totally extraperitoneal laparoscopic inguinal hernia repair using a polyester anatomical mesh

Background Laparoscopic hernia repairs have been gaining worldwide popularity, especially totally extraperitoneal (TEP) repair. The choice of prosthesis became a very important factor as a determinant of the outcome. Polyester anatomical mesh provides enough coverage of hernia defect with many benefits of its polyester-based chemistry. Aim The aim of the study was to assess the short-term outcomes of laparoscopic TEP repair using a polyester anatomical mesh regarding its safety, efficacy, and impact on patient’s quality of life (QOL). Patients and methods A prospective assessment of 20 adult patients with uncomplicated inguinal hernia, who underwent laparoscopic TEP repair using polyester anatomical mesh between June 2015 and May 2016 at Tanta University Hospitals. The patient’s QOL was checked preoperatively, at 3 and 6 months postoperatively (PO) using the visual analog scale. The follow-up period was 6 months. Results The mean age of the patients was 46.18±18.35 years. The mean operative time was 69.7±25.1 min. There were no conversions to other procedures or major complications. The most common operative complication was peritoneal tears in seven (33.3%) hernias. Most common PO complication was small hematoma at the umbilical port in two (10%) patients, which resolved spontaneously. The mean time to return to daily activities was 4.1±0.54 days. There were no recurrences or mesh-related complications. The patient’s QOL significantly improved 6 months PO. Conclusion Laparoscopic TEP inguinal hernia repair using polyester anatomical mesh without fixation is feasible and safe. It is associated with no chronic pain, no recurrence, minor complications, and better QOL.

Spinal anesthesia is safe in laparoscopic total extraperitoneal inguinal hernia repair. A retrospective clinical trial.

IntroductionLaparoscopic total extraperitoneal (TEP) inguinal hernia repair is an effective and safe method for the treatment of inguinal hernia. There are very few studies on regional anesthesia methods in TEP surgery.AimTo compare TEP inguinal hernia repair performed when the patient was treated under spinal anesthesia (SA) with that performed under general anesthesia (GA).Material and methodsAll total of 80 patients were studied between December 2015 and March 2017. Hyperbaric bupivacaine and fentanyl were used for SA, to achieve a sensorial level of T3. Propofol, sevoflurane, rocuronium, fentanyl, and tracheal intubation were used for GA. Intraoperative events related to SA, surgical times, intra- and postoperative complications, and pain scores were recorded.ResultsThe mean operative time in the SA TEP group was 70.2 ±6.7 min, which was significantly longer than the mean operative time in the GA TEP group of 67.2 ±6.2 min (p < 0.038). The mean pain scores in the SA TEP group were 0.23 ±0.42 at the first hour, 1.83 ±0.64 at 6 h and 1.28 ±0.45 at 24 h. These scores were significantly lower than the corresponding scores of 5.18 ±0.84 (p < 0.001), 2.50 ±0.55 (p < 0.001) and 1.58 ±0.55 in the GA TEP group. Generally, patients were more satisfied with SA than GA (p < 0.004).ConclusionsSpinal anesthesia TEP is significantly less painful in the early postoperative period, leading to earlier ambulation than GA TEP. Additionally, SA TEP results in significantly less need for analgesics and better patient satisfaction results. SA TEP seems to be a better alternative than the existing GA TEP.

Laparoscopic totally extra peritoneal (TEP) inguinal hernia repair: A series of 47 cases

Background: Over the past years, several surgical techniques have been evolved, among which total extraperitoneal inguinal hernia repair is the laparoscopic technique which is more popular now.Objective: To evaluate the outcome of totally extra peritoneal laparoscopic hernioplasty in terms of operation time, hospital stay and complications.Methods: The prospectively designed descriptive study was carried out at Department of Surgery Unit III, Kathmandu Medical College Teaching Hospital from February 2014 to April 2015. Forty seven consecutive patients above 15 years of age underwent totally extra peritoneal repairs for inguinal hernias. The selection criteria were reducible primary or recurrent, unilateral, direct and indirect inguinal hernias. All the relevant details of each patient were noted subsequently and analyzed statistically using Statistical Program for Social Sciences (SPSS) version 15.Results: The mean age of patient was 49±2.5 years. The mean operation time was 65±5.3 minutes. There were no serious complications except four (8.5%) cases of groin seroma which resolved after single time aspiration. Three (6.3%) cases had developed recurrence, two (4.2%) had developed hydrocele in a median follow up period of 6±1.5 (range, 3-9months). The mean inpatient hospital stay was 1.7±0.2 (range, 1-2.4days).Conclusion: Total extra peritoneal hernioplasty is safe and feasible with acceptable complications and recurrence rates.Journal of Kathmandu Medical College, Vol. 5, No. 4, Issue 18, Oct.-Dec., 2016, page: 120-123

Pre-peritoneal local anaesthetic does not reduce post-operative pain in laparoscopic total extra-peritoneal inguinal hernia repair: double-blinded randomized controlled trial.

Laparoscopic total extra-peritoneal hernia repair (TEP) is associated with less post-operative pain and earlier return to normal activity compared to open hernia repair (OHP). Despite this, post-operative pain remains a major issue. The aim of this double-blinded randomized controlled trial was to identify whether the instillation of local anaesthetic in the pre-peritoneal space improves pain scores following TEP. One hundred patients undergoing laparoscopic total pre-peritoneal hernia repair (TEP) between the years of 2009-2014 were included. Patients were randomly assigned to receive either 20mL of normal saline or 0.25% bupivacaine with adrenaline. Visual analogue scores (VAS 0-10) were recorded post-operatively at the 4h, 1day, 2weeks, and 6week mark. Secondary endpoints included complications, time to discharge, and return to normal activity. 51 patients were allocated to the local group. 49 patients were allocated to the placebo group. The baseline characteristics and demographics of patients in both groups were comparable. Patients in the local group had similar VAS scores compared to the placebo group at both 4h (1.1 vs. 1.4, respectively; p=0.19) and 24h (2.1 vs. 2.3; p=0.63). No statistically significant difference noted in other primary and secondary outcomes. Although the concept of pre-peritoneal local anaesthetic instillation following laparoscopic TEP is attractive, this appropriately powered study has failed to show any advantage in pain scores at 4 and 24h. The pain scores recorded, however, were remarkably low in both groups.

Cadaveric Dissection vs Homemade Model: What is the Best Way to Teach Endoscopic Totally Extraperitoneal Inguinal Hernia Repair?

Endoscopic totally extraperitoneal inguinal hernia repair (TEP-IHR) requires practice and training to perform well. We developed a simple, low-cost, inanimate model to teach surgical residents inguinal anatomy and the technique of mesh insertion for a safe, endoscopic TEP-IHR. The objective of this study was to compare our model vs cadaveric dissection for teaching anatomy and mesh insertion. A total of 14 general surgery residents participated in an institutional review board approved, prospective, and randomized study. Participants received a timed, web-based, interactive pretest assessing relevant anatomy and operative-based techniques. They then performed endoscopic TEP-IHRs on either a cadaver or our low-cost model. Participants then received a timed, web-based interactive posttest consisting of the same questions. Participants were surveyed anonymously regarding the degree to which either the model or the cadaver was educationally effective. Both groups of trainees (cadaver = 7, low-cost model = 7) scored higher on the posttest (p<0.05) with similar improvement (cadaver group: pretest = 78% correct, posttest = 87%; low-cost model group: 77% vs 86%). Survey results revealed the trainees preferred for both initial learning and understanding of mesh placement using low-cost models (5 out of 5, 4.8/5, respectively) over cadavers (4.0/5, 3.8/5, respectively; p<0.05). Trainees preferred the cadaver (4.7) over the low-cost model (3.9, p<0.05) in overall experience. No differences were found in the trainees' preference between the cadaver (4.5) and low-cost model (4.7) in the overall educational value. While the overall educational experience of 14 learners favored a cadaver experience to learn TEP-IHR, initial anatomical learning and placing the mesh was better with an inanimate model. Given the educational value of the 2 methods was equivalent, the $1500 cost for cadavers make the inexpensive and repeatable inanimate model an attractive early resource for learning TEP-IHR.

Bilateral endoscopic totally extraperitoneal (TEP) inguinal hernia repair does not impair male fertility.

Endoscopic totally extraperitoneal (TEP) hernia repair with polypropylene mesh has become a well-established technique. However, since the mesh is placed in close contact with the spermatic cord, mesh-induced inflammation may affect its structures, possibly resulting in impaired fertility. The aim of this observational prospective cohort study was to assess fertility after bilateral endoscopic TEP inguinal hernia repair in male patients. Fifty-seven male patients (22-60years old) with primary, reducible, bilateral inguinal hernias underwent elective bilateral endoscopic TEP hernia repair with use of polypropylene mesh. The primary outcome was testicular perfusion; secondary outcomes were testicular volume, endocrinological status, and semen quality. All patients were assessed preoperatively and 6months postoperatively. Follow-up was completed in 44 patients. No statistically significant differences in measurements of testicular blood flow parameters or testicular volume were found. Postoperative LH levels were significantly higher [preoperative median 4.3IU/L (IQR 3.4-5.3) versus postoperative median 5.0IU/L (IQR 3.6-6.5), p=0.03]. Levels of inhibin B were significantly lower postoperatively [preoperative median 139.0ng/L (IQR 106.5-183.0) versus postoperative median 27.0ng/L (IQR 88.3-170.9), p=0.01]. No significant changes in FSH or testosterone levels were observed. There were no differences in semen quality. Our data suggest that bilateral endoscopic TEP hernia repair with polypropylene mesh does not impair fertility, as no differences in testicular blood flow, testicular volume, or semen quality were observed. Postoperative levels of LH and inhibin B differed significantly from preoperative measurements, yet no clinical relevance could be ascribed to these findings.

Total extraperitoneal approach in inguinal hernia repair: an update

Inguinal hernia can be repaired through numerous approaches either by conventional open or endo-laparoscopic technique. Few factors are contributing to the increasing popularity of endo-laparoscopic approach: firstly the several studies that showed the benefits and advantages of the technique then, the widest application of laparoscopic techniques in all fields of surgery including advanced procedures, making the, once defined “difficult to learn”, endoscopic hernia repair easier and lastly, the improvement of imaging technology from high definition to the 3D. Total extraperitoneal (TEP) inguinal hernia repair requires a proper training and a good standard technique in order to be mastered with low recurrence and complications.

Methodical endoscopic repair of congenital indirect inguinoscrotal hernia in adult male patients with completely patent processus vaginalis.

Indirect inguinal hernia related to the presence of a patent processus vaginalis (PPV) in adult is estimated to be around 15%. Most surgeons would favor a standard anterior hernioplasty to minimize the potential risk of damaging the spermatic cord structures that are always intimately fused to the congenital peritoneal sac. This also means overlooking the potential benefit of alternative posterior techniques such as endoscopic totally extraperitoneal (TEP) repair that is known to offer faster recovery with reduced risk of developing chronic groin pain. The aim of this study was to evaluate the safety of TEP approach for repair of adult inguinoscrotal hernias associated with completely PPV and to compare those results with a corresponding group of male patients undergoing an identical procedure, but with no demonstrated PPV. This is a prospective study of consecutive male patients diagnosed with inguinal hernia during a 10-year period and eligible for endoscopic TEP repair. Every recognized completely PPV were systematically divided taking care not to damage the attached cord structures and the proximal end closed with a pre-tied Endoloop of PDS. In both groups, all meshes were secured with fibrin sealant only. Patients were reviewed in clinic 2 and 6weeks after the operation. Further follow-up was scheduled if deemed necessary. The primary post-operative outcome parameter was spermatic cord injury; secondary outcome parameters included groin pain, surgical complications, and recurrence. Nine hundred and thirty-nine hernia repairs were prospectively recorded during this period. All procedures were carried out endoscopically. A total of 41 patients with a median age of 27years presented with 43 inguinoscrotal hernias (two bilateral) related to the presence of a congenital completely PPV. 72% of them were right-sided. No injury to the cord structures was recorded and only one complication (2.4%) occurred at 1week post-operatively that was unrelated to the PPV. There was no report of chronic groin or testicular pain, symptomatic seroma formation, or hernia recurrence. By comparison, out of the 608 patients representing the no PPV group, there were 35 complications out of 33 patients (5.4%), one of those requiring subsequent laparoscopic revision. Only one early post-operative recurrence was recorded in this group (0.15%). In the presence of a completely PPV, the recognized benefit of a posterior approach, such as endoscopic TEP inguinal hernia repair, outweighs the theoretical risk of damaging the spermatic cord structures when dissecting and dividing the congenital hernia sac. This technique should be the preferred option among expert laparoscopic surgeons.

A prospective comparative study of total extraperitoneal inguinal hernia repair: fixation versus without fixation of the mesh

Background:Mesh fixation during laparoscopic total extra-peritoneal (TEP) inguinal hernia repair is still controversial. Although many surgeons considered it necessary to fix the mesh, some published studies supported elimination of mesh fixation. Therefore, a randomized prospective comparative study was conducted in JSS Hospital to compare the postoperative pain, cost effectiveness and recurrence of fixation versus without fixation of mesh.Methods: A randomized prospective comparative study was carried out in 30 patients who underwent laparoscopic TEP inguinal hernia repair with (Group A) or without (Group B) fixation of the mesh. The postoperative pain scores are analyzed and compared by visual analogue scale at 24hrs, 1 week, and 1 month in both groups. The recurrence rate is analyzed and compared by follow up of patients after 6months in both groups. The cost effectiveness is compared in both groups in monetary terms.Results:Patients in whom the mesh was not fixed had less postoperative pain (median of VAS is 4 in group A and 2 in group B, p ≤ 0.0001), mean lesser cost of surgery (Rs. 13135 in group A and Rs. 9245 in group B, p≤ 0.0001). No hernia recurrences were observed in either group (follow up period of 6months).Conclusions:Elimination of fixation of mesh during TEP inguinal hernia repair significantly reduces the postoperative pain and cost of surgery and it does not lead to increased rate of recurrence.

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.

Long-term follow-up of laparoscopic total extraperitoneal (TEP) repair in inguinal hernia without mesh fixation

From the current evidence, non-fixation of the mesh (NMF) in laparoscopic total extraperitoneal (TEP) repair appears to be a safe alternative for inguinal hernia patients in the short term. This study aims to demonstrate that NMF is as effective in the long term by following up a large number of patients with a mean follow-up of 6years. The primary outcomes are chronic pain and recurrence rate. A thorough review of medical records was conducted from a prospectively maintained database of 538 patients who underwent a laparoscopic TEP inguinal hernia repair by a single surgeon working in Sydney from the year 2005 to 2010. Patient demographics, perioperative outcomes, and postoperative complications were extracted from this database. All these patients were then interviewed using a modified questionnaire based on Franneby et al. [10]. 538 patients had TEP repair between 2005 and 2010. Out of this 11 were excluded as tacks were used for fixation of mesh. Out of the 649 repairs done on 527 patients during this period, 463 hernia repairs in 387 patients could be followed up with a mean follow-up of 6years and 4months. The mean age of patients was 63years. Overall, there were seven (1.5%) recurrences, and the incidence of chronic pain was 1%, however 2.9% patients in total complained of pain. This is the only study in literature having a long-term follow-up of more than 5years for the patients having inguinal hernia repair by TEP technique without mesh fixation. It demonstrates that fixation of mesh with tacks or glue is unnecessary for TEP repair of inguinal hernia.

Patient-reported outcomes (PROs) after total extraperitoneal hernia repair (TEP)

BackgroundPatient-reported outcomes (PROs) such as quality of life (QoL), patient satisfaction, and work impairment, are arguably the most important outcomes of any medical treatment. In 2011, Staerkle and Villiger developed the Core Outcome Measurements Index (COMI) to standardise PROs and PRO measurement for inguinal hernia patients, in an attempt to increase inter-study comparability. The aim of this study is to prospectively evaluate the short- and long-term postoperative QoL, function, patient well-being, pain, and social/work disability, after total extraperitoneal (TEP) inguinal hernia repair and to provide the first clinical experience with the COMI-hernia questionnaire.MethodsBetween January 2013 and December 2014, all patients ≥18 years that were scheduled for elective uni- or bilateral TEP in a regional hospital were approached to participate in this study. Measurements were taken preoperatively, and 6 weeks and 1 year postoperatively.ResultsOne hundred and twenty patients (113 men, 7 women), mean age 59 years (SD ±12), completed the follow-up of 1 year. Ninety-seven percent of the population reported that the operation improved their complaints. QoL, function, well-being, and pain all improved after 6 weeks and 1 year after surgery. Patients experienced more social and work-related limitations 6 weeks after surgery compared to baseline measurements, though this improved to normal 1 year postoperatively. The incidence of chronic pain was 14% (VAS ≥ 2), which had a negative impact on the patients' sense of well-being.ConclusionPatients recovered well after TEP repair with a good quality of life and fast restore of function. Patient well-being was lower than expected due to a 14% incidence of chronic pain. The COMI-hernia scale provided reasonable insight into the patients' experience, though it was difficult to interpret for both patient and physician.

Lightweight Titanium-coated Mesh Versus Standard-Weight Polypropylene Mesh in Totally Extraperitoneal Inguinal Hernia Repair (TEP): A Cohort Analysis.

The study objective is to compare the outcomes of laparoscopic to tally extraperitoneal repair using the standard-weight polypropylene mesh or a lightweight titanium-coated mesh. A retrospective review was conducted on 138 adult patients with unilateral inguinal hernias, who underwent totally extraperitoneal inguinal hernia repair between 2010 and 2013 using either a standard-weight polypropylene mesh (Prolene mesh, 80 g/m) or a lightweight titanium-coated mesh (Ti Mesh light, 35 g/m). There was no difference in reported pain at 24 hours postoperatively. The difference in reported pain at follow-up (mean: 21 mo) was insignificant [PP vs. Ti: 7.8% (n=5) vs. 8.3% (n=3), P=0.92], the differences regarding chronic inguinal pain was also insignificant [PP vs. Ti: 14% (n=9) vs. 5.5% (n=2), P=0.191], and there was no difference in the development of hernia recurrence [PP vs. Ti: 1.5% (n=1) vs. 0, P=0.42]. No statistically significant differences of the overall postoperative outcome were observed between the 2 mesh types.

Totally extraperitoneal (TEP) bilateral hernioplasty using the Single Site® robotic da Vinci platform (DV-SS TEP): description of the technique and preliminary results.

Laparoendoscopic single site totally extraperitoneal (TEP) hernia repair showed to be a feasible alternative to conventional laparoscopic hernia repair; nevertheless single site surgery, with the loss of instruments triangulation can be a demanding procedure. To overcome those hurdles, the Single Site® (SS) platform of the da Vinci (DV) Si robotic system enables to perform surgical procedures through a 25-mm skin incision, with a stable 3D vision and restoring an adequate triangulation of the surgical instruments. We present in details the technique and the preliminary results of DV-SS TEP, to our knowledge the first cases reported in literature. In March 2016, three consecutive male patients (mean age 46.6years-mean BMI 25.3) with bilateral symptomatic inguinal hernia were submitted to DV-SS TEP in our institutions. Feasibility, codification of the technique, operative time and perioperative outcomes were recorded. All the procedures were completed as scheduled, with no conversion to other techniques. Mean operative time was 98.6min, ranging between 155 and 55min, reflecting the learning curve of the operating room team on this new procedure. No intraoperative or postoperative complications were experienced and all the patients were discharged within 24h after surgery. Patients reported satisfactory postoperative course, with no recurrence of inguinal hernia and satisfaction in cosmetic result at 6-month follow-up. DV-SS TEP inguinal hernia repair showed to be feasible and effective surgical option for bilateral groin hernia repair. Patients' outcome was uneventful, with optimal cosmetic results. Further studies comparing this innovative technique to TEP or LESS TEP should be promoted.

The Superior Inguinal Ligament Approach of Single Incision Laparoscopic Surgery for Total Extraperitoneal Inguinal Hernia Repair.

Total extraperitoneal (TEP) inguinal hernia repair gained popularity in the past two decades for its advantage, especially single incision laparoscopic surgery (SILS) for TEP inguinal hernia repair (SILS TEP), however, which is a technically demanding procedure. The study retrospectively analyzed 6 cases of the superior of inguinal ligament approach of S-SILS TEP repair from August 2015 to July 2016. A detailed review of medical records and the perioperative data including patient characteristics, operative details, and postoperative hospital stay was conducted. S-SILS TEP repair for inguinal hernia was successfully completed for 6 patients, and the mean operation time was 59.2 minutes (range 55-70 minutes), and the mean blood loss was 7.5 mL (range 5-15 mL) and the postoperative recovery was uneventful about 3 days after operation with a single wound over inguinal ligament. S-SILS TEP repair provides a new operative view, which combines the advantage of laparoscopic and open surgery, especially in surgical technique and minimal invasiveness. Our experience suggests that the S-SILS TEP repair may be a safe and feasible alternative in inguinal hernias repair.

Mini Totally Extra-Peritoneal Repair of Inguinal Hernia with All 5 mm Ports: An Innovative "555 Technique".

Totally extra-peritoneal (TEP) repair of inguinal hernia is now a standard surgical technique. A 12 mm incision in infra-umbilical region for Hasson trocar is must for TEP repair of inguinal hernia. This is the only technique known to laparoscopic surgeons. We have innovated a "555 Technique" for completing Mini TEP repair of inguinal hernia by using all three 5 mm ports. Sixty-one consecutive patients were subjected for TEP repair of inguinal hernia by our innovative "555 Technique" since October 2014. A simple "Manish Retractor" is devised to make extra-peritoneal space with 5 mm trocar. Fifty-nine cases were men and 2 cases were women. The mean age of patients was 44.6 years (range 23-82 years). Out of 61 cases, 27 were indirect inguinal hernia (23 unilateral, 4 bilateral), 32 direct inguinal hernia (21 unilateral, 11 bilateral), 1 femoral hernia, and 1 obturator hernia. One patient of indirect inguinal hernia had sliding hernia with sigmoid colon. Sixty cases were successfully operated by "555 Technique." There was conversion to trans-abdominal pre-peritoneal repair (TAPP) in 1 case. The average time for insertion of 5 mm trocar in preperitoneal space by our technique was 150 seconds. No complications were noted on 6 months follow-up. Small infra-umbilical scar was cosmetically more acceptable to patients. "555 Technique" is a feasible option without compromising the principles of TEP repair for inguinal hernia. Innovation of simple "Manish Retractor" is the key in completing Mini TEP repair. This technique is simple, less invasive, less morbid, and cost effective as it avoids dependence over costly Hasson trocar with better cosmetic results.

Laparoscopic total extraperitoneal repair under spinal anesthesia versus general anesthesia: a randomized prospective study.

BackgroundLaparoscopic total extraperitoneal (TEP) inguinal hernia repair is a well-known approach to inguinal hernia repair that is usually performed under general anesthesia (GA). To date, no reports compare the efficacy of spinal anesthesia (SA) with that of GA for laparoscopic hernia repairs. The purpose of this study was to compare the surgical outcome of TEP inguinal hernia repair performed when the patient was treated under SA with that performed under GA.Materials and methodsBetween July 2015 and July 2016, 50 patients were prospectively randomized to either the GA TEP group (Group I) or the SA TEP group (Group II). Propofol, fentanyl, rocuronium, sevoflurane, and tracheal intubation were used for GA. Hyperbaric bupivacaine (15 mg) and fentanyl (10 µg) were used for SA to achieve a sensorial level of T3. Intraoperative events related to SA, operative and anesthesia times, postoperative complications, and pain scores were recorded. Each patient was asked to evaluate the anesthetic technique by using a direct questionnaire filled in 3 months after the operation.ResultsAll the procedures were completed by the allocated method of anesthesia as there were no conversions from SA to GA. Pain was significantly less for 1 h (P<0.0001) and 4 h (P=0.002) after the procedure for the SA and GA groups, respectively. There was no difference between the two groups regarding complications, hospital stay, recovery, or surgery time. Generally, patients were more satisfied with SA than GA (P<0.020).ConclusionTEP inguinal hernia repair can be safely performed under SA, and SA was associated with less postoperative pain, better recovery, and better patient satisfaction than GA.

Efficacy of Local Anesthetic With Dexamethasone on the Quality of Recovery Following Total Extraperitoneal Bilateral Inguinal Hernia Repair

Quality of recovery (directly associated with patient satisfaction) is an important clinical outcome measurement and a surrogate of anesthetic/surgical care quality. To compare the efficacy of a transversus abdominis plane (TAP) block with dexamethasone sodium phosphate and preperitoneal instillation of local anesthetic (PILA) with dexamethasone vs control on postoperative quality of recovery following a bilateral total extraperitoneal inguinal hernia repair (TEP-IHR) (>24 hours). Secondary objectives included efficacy of this technique on postoperative opioid use, nausea and vomiting, and pain scores. Conducted from November 2013 to August 2015, this randomized, prospective, single-blinded study compared 2 groups (a TAP block and PILA) with a standard anesthetic technique with no regional technique (control) following bilateral TEP-IHR. This study at the Veterans Affairs Medical Center (Indianapolis, Indiana) included patients ages 18 to 80 years with an American Society of Anesthesiologists physical status of 1 to 3 scheduled for an outpatient bilateral TEP-IHR. Nurses assigning pain scores and administrating opioids for pain and staff anesthesiologists administering the Quality of Recovery-40 (QoR-40) questionnaire were blinded. Patients randomized to receive a TAP block with local anesthetics and dexamethasone, PILA with dexamethasone, or no regional technique (3 groups). Patient's response to the QoR-40 questionnaire following a TEP-IHR surgery. The mean (SD) ages in the TAP block (n = 19), PILA (n = 24), and control (n = 23) groups were 58.2 (9.4) years, 62.5 (8.1) years, and 62.9 (7.8) years, respectively. The global QoR-40 scores on postoperative day 1 for the TAP block group (median [interquartile range (IQR)], 178 [173-188]) were comparable with the control group (median [IQR], 174 [150-181]), while the PILA group had better global QoR-40 scores (median [IQR], 184 [175.5-190.75]) (P = .002). The effects of the TAP block and PILA on pain in the postoperative care unit (PACU) (median [IQR], 1 [0-5] and 3.5 [0-6.8], respectively), pain after discharge (median [IQR], 3 [2-5] and 3 [1-5.5], respectively), opiate use after discharge (median [IQR], 6.7 [5-10] and 6.7 [3.3-10], respectively), and incidence of nausea and vomiting in the PACU (4 of 19 [21.1%] and 6 of 24 [25%], respectively) were not significantly different from the control group (median [IQR], 4 [3-6] for pain scores in the PACU; 4 [3-7] for pain scores after discharge; 6.7 [3.3-10] for opioid use after discharge; and 6 of 23 [26.1%] for incidence of nausea/vomiting in the PACU). While there was a significant reduction of opioid use in the PACU in the TAP block group (median [IQR], 0 [0-1.3]) when compared with the control group (median [IQR], 4 [1.3-6.7]) (P = .001), this was not seen in the PILA group (median [IQR], 2 [0-6.4]). This study demonstrates a better quality of recovery in patients' receiving PILA with dexamethasone compared with control for a TEP-IHR surgery. clinicaltrials.gov Identifier: NCT02036983.

An Innovative “555 Technique” for Totally Extra-Peritoneal Repair of Inguinal Hernia Using All 5 mm Ports

Introduction: Three ports (one 10 mm Hasson trocar and two 5 mm ports) technique for total extra-peritoneal (TEP) repair of inguinal hernia is standard nowadays.1 We all have dependence on 10 mm Hasson trocar to create preperitoneal space (PPS) and mesh insertion. Hasson trocar leads to a large defect in the anterior rectus sheath and a large wound. It causes increased morbidity in terms of pain, high incidence of surgical site infection (SSI), high chances of incisional hernia, and suboptimal cosmetic outcome in comparison with 5 mm port wound.2,3 Dependence and necessity of having a costly Hasson trocar exclusively for TEP repair are reflected in surgical cost. Morbidity management of a larger port site wound also has financial impact on the patients.4 We have devised an innovative “555 Technique” by using all three 5 mm ports (Endopath XCEL Bladeless Trocar) to create PPS, dissection of sac, and insertion and placement of mesh without any difficulty. A 5 mm infra-umbilical incision is made to create PPS under vision. A 2 mL plastic syringe hub is cut and used as a retractor to make an incision in the anterior rectus sheath. The other two 5 mm working ports are used for dissection of sac and mesh placement. Our technique avoids the use of the costly Hasson trocar to create PPS. Materials and Methods: From October 21, 2014 to July 30, 2015, 30 consecutive TEP repairs were done using our new “555 Technique.” Results: Thirty patients (28 males, 2 females) were operated using the “555 Technique.” The mean age of the patients was 43 years, ranging from 23 to 76 years. Of the 30 patients, 13 patients had indirect inguinal hernia (11 unilateral and 2 bilateral) and 17 patients had direct inguinal hernia (7 unilateral and 10 bilateral). Two unilateral indirect inguinal hernias were irreducible. Both the females were having indirect inguinal hernia. The average time for insertion of the 5 mm trocar in PPS using our technique was 170 seconds, which is less than the insertion time of the conventional Hasson trocar placement. Pneumoperitoneum occurred in four cases, which was managed by putting Veress needle into the peritoneal cavity. All 30 cases were effectively operated using the “555 Technique.” During the postoperative period, analgesic requirement was less because of all the 5 mm ports. There was no incidence of SSI, hernia recurrence, or incisional hernia formation. Small infraumbilical scar is cosmetically more acceptable to patients. Conclusion: The “555 Technique” is a feasible option without compromising the principles of TEP repair for inguinal hernia. It is cost effective as it avoids dependence on the costly Hasson trocar and gives less morbidity and better cosmetic results. No competing financial interests exist. Runtime of video: 7 mins 13 secs