Unilateral Totally Extraperitoneal Research Articles

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

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

Laparoscopic Inguinal Hernia Repair: Transabdominal Preperitoneal or Totally Extraperitoneal? Results of a 14-year Prospective Study.

Background: Laparoscopic inguinal hernia repairs are most commonly either transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) operations. The indications and comparative outcome data for both approaches are often conflicting and thus we sought to compare the two. Methods: 678 consecutive laparoscopic inguinal hernia repairs (190 TAPP and 488 TEP) were prospectively recorded onto a database from June 2004-December 2018. Age, gender, hernia characteristics, operative times, complication and 12-month recurrence rate data were compared. Results: 49.5% of TAPP repairs were recurrent hernias, and 95.5% of TEP repairs were bilateral hernias. TAPP patients were significantly older than TEP patients (60.65 versus 55.60, p 0.01). Unilateral TAPP repairs had a significantly shorter operative time than unilateral TEP repairs (50.94 versus 65.71 minutes, p=0.01). There was no significant difference in overall complication rate between TAPP and TEP repairs (6.84% versus 7.38%, p=0.87), and this was consistent across different hernia groups. TAPP repairs recurred at a significantly higher rate than TEP repairs (3.16% versus 0.61%, p=0.02) overall, but recurrence rates were not significantly different when broken down by hernia group. Conclusions: Applying the broad principle of utilizing the TAPP approach for recurrent hernias and the TEP approach for bilateral hernias, outcomes from both operations are similar.

Recurrence after totally extraperitoneal (TEP) inguinal hernia repair: the role of physical examination and ultrasound.

Physical examination (PE) combined with ultrasound (US) is recommended to confirm a recurrent hernia. However, the evidence is rather weak. The aim of this study was to evaluate PE and appraise the added value of US in alleged recurrent inguinal hernias after totally extraperitoneal (TEP) inguinal hernia repair. All adult patients who were re-operated for suspicion of a recurrent hernia after a primary unilateral or bilateral TEP between 2006 and 2017 were identified and investigated retrospectively. Patient characteristics, PE, additional imaging and intra-operative findings were registered. PE outcomes were compared with intra-operative findings to calculate the positive predictive value (PPV) of PE. In case of clinical doubt, the added value of US was evaluated by comparing US findings with the intra-operative findings. A total of 130 patients were re-operated for suspicion of 137 recurrent hernias. In 75 patients, US was performed. PE was positive for an inguinal hernia in 101 groins (73.7%), negative in 30 (21.9%) and inconclusive in 6 (4.4%). PE matched the operative findings in 75.2%. The PPV of diagnosing a recurrent hernia (or lipoma) on PE was 97%. In case of clinical doubt (n = 36), positive US matched the operative findings in 20 cases (87.0%). US does not necessarily need to be incorporated in the standard diagnostic workup of a recurrent inguinal hernia. After PE alone, a recurrent hernia (or lipoma) can be diagnosed with a PPV of 97%. Only in case of clinical doubt, US has additional value.

Cognitive task analysis of the laparoscopic totally extraperitoneal (TEP) inguinal hernia repair: Efficiency, slow-down moments and teaching principles

Introduction The TEP repair is associated with a learning curve of at least 250 repairs. Expert surgeons' decision-making becomes automated, making it difficult for them to recognize and teach their decision-making process. We sought to deconstruct the intraoperative decision-making of the TEP repair in order to discern the key cognitive and technical teaching principles. Methods Five expert TEP surgeons participated in an individual critical decision method-based cognitive task analysis interview, supervised by an educational psychologist. Experts were asked to recall and describe their last unilateral TEP repair. Recordings were transcribed, and cognitive demand tables were created outlining operative and decision making steps. Thematic analysis was then conducted to identify common operative strategies, and agreement between experts was compared. Results Analysis of transcripts revealed 26 operative and 23 decision-making steps, yielding 9 themes: efficiency, troubleshooting, slow down moment, critical step, error avoidance, cost-saving, patient-specific, surgeon-specific, and teaching principles. Each theme had areas of overlap as well as unique operative strategies (among 13 teaching principles identified, 10 were common to >1 surgeon and 3 were unique to only one surgeon). Experts were more likely to agree in operative than in decision making steps (81% vs 56%, p Conclusions Cognitive task analysis with experienced TEP hernia surgeons identified strategies to improve efficiency, discovered critical operative cues and outlined key teaching principles for the TEP repair. These results can be integrated into instructional programming and clinical training to facilitate growth and acquisition of procedural decision making of surgical trainees.

Simultaneous Laparoscopic Totally Extraperitoneal Repair of Bilateral Inguinal Hernia

This study evaluated the outcomes of laparoscopic totally extraperitoneal (TEP) simultaneous bilateral hernia repair with regard to the effectiveness and the complications compared with those of unilateral laparoscopic TEP hernia repair. One hundred twelve patients underwent laparoscopic TEP for bilateral inguinal hernia and 767 patients underwent laparoscopic TEP for a unilateral hernia from March 2004 to January 2010. The mean age of the patients was older in bilateral group than that in the unilateral group, and the proportion of female patients was lower in the bilateral group. The distribution of the types of hernia was different in both the groups (P<0.001). The mean operation time and the mean patient cost for TEP in the bilateral group were 1.5 times longer and more expensive than that in the unilateral group. However, there were no differences in the mean number of hospital days and postoperative complications. There was 1 recurrence in the bilateral group, but it had no statistical significance (P=0.127). Laparoscopic TEP repair is safe and feasible for treating bilateral inguinal hernia. Bilateral repair also has some advantages such as no additional admission, a decreased operation time, and cost-effectiveness.

Comparison of Totally Extraperitoneal Technique and Darn Plication of Primary Inguinal Hernia

This prospective, randomized, controlled clinical study aimed to assess the perioperative and long-term results of primary inguinal hernia repair and to compare the results for a totally extraperitoneal (TEP) procedure with the results of patients undergoing darn plication. For this study, 166 patients with unilateral inguinal hernias were randomly assigned to undergo either TEP (n=78) or darn plication (n=88). The mean operation time for darn plication (16±14.7 minutes) was significantly shorter than TEP hernioplasty (42.1±35.6 minutes, P=.007), but the postoperative recovery time and return to work were significantly less shorter for TEP (P=.001). The frequencies of complications (11.5% versus 12.5%) and recurrences (2.5% versus 3.4%) were approximately equal in the two groups. The frequency of chronic groin pain (2.5% versus 14.1%, P=.008) and numbness (1.2% versus 6.8%, P=.01) was significantly lower in the TEP group. The majority of patients (92%) receiving TEP reported being "very satisfied" with the outcome of surgery compared with only 68 (77.2%) "very satisfied" patients in the darn group (P=.01). TEP repair is comparable to darn plication in terms of complications and recurrences. Unilateral TEP can be safely and efficiently accomplished in less than 45 minutes, even during the initial learning phase. TEP is more comfortable for patients and results in earlier ambulation and return to work. The qualitative accounts given by the patients also support the advantages of TEP in postoperative period.

Laparoscopic totally extra-peritoneal inguinal hernia repair: 9 year’s experience

Major innovations continue to occur in the operative techniques used in hernia operations. Laparoscopic totally extra-peritoneal (TEP) hernia repair is the latest addition to the long list of operations used for hernia repair. The objectives of this study were to assess the safety and efficacy of this relatively new procedure and to discuss various technical aspects to make the procedure easy to learn. Patients who underwent elective inguinal hernia repair from January 2000 to December 2008 were included in this ongoing prospective clinical study. Patient demographic data, operative records, perioperative findings, postoperative morbidity and outpatient follow-up of TEP repairs were studied. Out of 1,814 hernia operations, 1,539 (84.84%) were performed by laparoscopic TEP repair and 275(15.16%) were operated by Lichtenstein repair. There were 19 conversions from attempted TEP to open surgeries. Mean operative time for unilateral TEP repair was 28±7min and for bilateral repair 36±8min The incidence of intra-operative complications was 2.98%. Overall morbidity rate was 8.57%. The usual hospital stay was 36h. The recurrence rate in first 3years was 8.00%, the next 3years, 2.05% and in the last 3years, 0.67%. The longest interval between operation and recurrence was 48months. Laparoscopic TEP repair is an excellent mode of treatment in the era of laparoscopic surgery. If the standard technique now established is followed, the procedure is easy to learn for a laparoscopic surgeon, the overall morbidity and complications are fewer in number and severity, and recurrence rates are lower.

Needlescopic Totally Extraperitoneal Hernioplasty for Unilateral Inguinal Hernia in Adult Patients

Totally extraperitoneal (TEP) inguinal hernioplasty for inguinal hernia is associated with less postoperative pain, shorter hospital stays, less chronic pain, and increased patient satisfaction when compared with the open Lichtenstein approach‥ However, only few studies to date have compared conventional with needlescopic TEP hernioplasty for treating unilateral inguinal hernias in adult patients. We report our prospective study that compared the postoperative outcomes of these two approaches over a 2-year period. From July 2007 to June 2009, a total of 32 patients underwent attempted unilateral needlescopic TEP hernioplasty. All data were prospectively collected and analysed, including demographic features, types of hernia, and postoperative outcome. The results were compared with those of an agematched cohort of 32 patients who underwent conventional TEP hernioplasty in the same period. Needlescopic TEP hernioplasty was successfully performed in 24 patients. The other eight procedures were completed with conventional TEP approaches after changing one or two 5-mm ports. The most common hernia type was Nyhus type III (38/64, 59.3%). There was no significant difference in the mean operative time, hospital stay, and postoperative pain scores between the needlescopic and conventional approaches. There was no major complication detected on the first visit, except seroma formation (9 patients in the needlescopic group and 11 in the conventional group), all of which was resolved with conservative management. No recurrence of hernia was noted in either group during the mean follow-up period of 88.0 weeks. Needlescopic TEP hernioplasty was a feasible technique in selected patients for inguinal hernia repair. Postoperative recovery following both approaches was similar. However, because this was a small cohort study, larger prospective, randomized controlled trials are required to establish the longterm benefit, safety and complications of needlescopic surgery.

Is unilateral laparoscopic TEP inguinal hernia repair a job half done? The case for bilateral repair

Bilateral laparoscopic totally extraperitoneal (TEP) repair of unilateral hernia is conspicuous in published literature by its absence. There are no studies or data on the feasibility, advantages or disadvantages of bilateral repair in all cases or in any subset of patients with unilateral primary inguinal hernia. The objective of this study is to investigate the feasibility of bilateral laparoscopic exploration for all unilateral cases followed by laparoscopic TEP in all cases and to compare complications, recurrence rates, postoperative pain, patient satisfaction, and return to work retrospectively with a similar number of age-matched retrospective controls. One hundred fifty TEP operations were performed in 75 patients (group A) prospectively and were compared with 75 unilateral TEP operations (group B) in age-matched controls done previously by the same surgeon. All cases were performed under general anesthesia, and TEP repair was performed using three midline ports. All uncomplicated patients were discharged at 24 h, in keeping with departmental policy. Of 75 patients (group A), 25 (33.3%) were clinically diagnosed with bilateral hernia and the rest (50, 66.66%) with unilateral hernia. The distribution of the 25 bilateral cases was 11 bilateral direct and 14 bilateral indirect inguinal hernias. The distribution of the 75 age-matched controls (group B) was all unilateral hernia, of which 47 were right-sided and 28 were left-sided. There were 23 direct hernias and 52 indirect hernias among the control group. The mean operative time for all 150 cases was 76.66 +/- 15.92 min. The operative time in the control group (unilateral hernias) was 66.16 +/- 12.44 min, whereas the operative time in the test group (bilateral repair) was 87.2 +/- 11.32 min. The operative time in the bilateral group was significantly higher, by 21.04 min or 31.88% (p = 0.000). The operative time in the true unilateral group was 82.45 +/- 9.38 min, whereas the operative time in the former group [occult contralateral hernias (OCHs) + bilateral hernias] was 91.35 +/- 11.95 min, which is a statistically significant difference (p = 0.0015). Occult hernia was seen in a total of 15 cases, of which 13 were OCHs (26%) and 2 were occult ipsilateral hernias (OIH). The mean operative time in the OCH cases was 81.46 +/- 7.9 min, whereas in those without OCH it was 82.45 +/- 9.38 min, which is not a statistically significant difference (p = 0.46). Regarding complications, there were no cases of seroma, hematoma, wound infection, visceral injury or postoperative neuralgia in either group A or B. On statistical analysis, visual analog score (VAS)-measured pain score, at 12 h only, was significantly higher in the unilateral repair group as compared with the bilateral TEP group; VAS scores at all other times were not statistically significantly different between the two groups. The average time of return to light routine or activities of daily living was 1 day in group A, whereas in group B it was 1.91 days (range 1-3 days), which is a statistically significant difference (p = 0.000). There was one case of recurrence in this study, in a left-sided hernia in group A, over a follow-up period of 60-72 (mean 66) months; all patients reported for follow-up by office visit or correspondence until 2 years, and two patients were lost to follow-up after 2 years. In group B, there was no recurrence over a follow-up period of 72-84 months, with three patients lost to follow-up after 3 years. In the present study bilateral TEP was performed in three types of patients: those with clinically bilateral hernias, those with clinically unilateral hernia but with an OCH, and in truly unilateral hernias. All of these were compared with unilateral TEPs in clinically unilateral hernias, and we found no significant increase in morbidity, pain, recurrence or complications in bilateral repairs. Convalescence from surgery, as determined by return to activities of daily living and return to work parameters, was also comparable. Surgeons experienced in laparoscopic TEP, in high-volume centers, can provide bilateral repairs in patients with inguinal hernia, bearing in mind its advantages and comparable morbidity. We also feel that, in elective repair of inguinal hernia, the patient should be given the option of bilateral repair. Bilateral repair does not add to the risk of surgery in experienced hands and we strongly feel that unilateral TEP is actually a job half done.

Acute pain after endoscopic totally extraperitoneal (TEP) inguinal hernioplasty: multivariate analysis of predictive factors.

Pain is the most common complaint after inguinal hernia surgery. The present study was undertaken to evaluate the significance of various perioperative clinical factors on the severity of postoperative pain following endoscopic totally extraperitoneal (TEP) inguinal hernioplasty. Between November 1999 and December 2002, 509 patients who underwent unilateral ( n = 389) and bilateral ( n = 120) TEP were recruited for this study. There were 491 men and 18 women. Severity of postoperative pain at rest and on coughing was assessed by a linear analogue pain score (scale, 0-10) on a daily basis after operation. Univariate and multivariate analyses were performed to identify the significant independent factors affecting pain. By univariate analysis, pain scores at rest were significantly higher in young (< or =65 years) female patients, as well as patients who underwent unilateral and day case TEP. Clinical factors associated with a significantly higher pain score on coughing included mesh fixation by stapling, female sex, and age (< or =65 years). Other factors, including unilateral vs bilateral TEP, seroma formation, direct vs indirect hernia, primary vs recurrent hernia, and operative time, had no impact on postoperative pain. On multiple regression analysis, age and sex were found to be independent predictive factors for mean daily pain score at rest. Independent factors influencing mean pain score on coughing included age, sex, and prosthetic stapling. Patient age and sex are the most significant factors determining the degree of pain after TEP. Analgesic therapy should therefore be adjusted in accordance with the age of the patient. With regard to operative factors, avoidance of prosthetic stapling might help to reduce the severity of pain on coughing.