Totally extraperitoneal laparoscopic hernioplasty versus open extraperitoneal approach for inguinal hernia repair: A meta-analysis of outcomes of our current knowledge

doi:10.1016/j.surge.2013.11.018

The Surgeon

Volume 12, Issue 2, April 2014, Pages 94-105

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Abstract

Background

The aim of this article is to explore the clinical effects between open extraperitoneal approaches and totally extraperitoneal laparoscopic hernioplasty (TEP) in the repair of inguinal hernias.

Methods

The electronic databases Pubmed, Medline, Embase, Web of science and the Cochrane Library were used to search for articles from January 1992 to March 2013. The present meta-analysis pooled the effects of outcomes of a total of 1157 patients with 1377 hernias enrolled into 10 randomized controlled trials and 2 comparative studies. The data was analyzed using the statistic software Stata12.0 and IBM SPSS Statistics 19.

Results

Significant advantages of totally extraperitoneal laparoscopic hernioplasty (TEP) compared to the open extraperitoneal approach include a lower incidence of total postoperative complications (Odds Ratio, 0.544; 95% confidence interval, 0.369–0.803), a reduction in urinary problems (0.206[0.064,0.665]), an earlier return to normal activities or work (SMD = −1.798[−3.322,−0.275]), and a shorter length of hospital stay (−1.995 [−2.358,−1.632]). No difference was found in operative time, the incidence of hernia recurrence, chronic pain, intraoperative complications, seromas or hematomas, wound infection and testicular problems between the two techniques. One significant advantage for the open extraperitoneal inguinal hernia repair was a lower incidence of peritoneal tears (46.504 [15.399,140.437]).

Conclusions

Totally extraperitoneal laparoscopic hernioplasty (TEP) and open extraperitoneal mesh repair are equivalent in most of the analyzed outcomes. TEP is associated with shorter hospital stay, quicker return to normal activities or work, lower incidence of total postoperative complications and urinary problems, while the open extraperitoneal method has less incidence of peritoneal tears.

Introduction

Inguinal hernia repair is one of the most common surgical operations in general surgery. Since Lichtenstein¹ described his tension-free hernioplasty in 1989, tension-free hernia repair was quickly accepted by most surgeons as the effective and safe method of hernia repair for its lower recurrence rate, less postoperative pain and easy to learn, various surgical methods were described and invented from that time on. In tension-free hernioplasty, a prosthesic mesh can be placed subaponeurotically or extraperitoneally, either through an open approach or laparoscopically.² With improved understanding of the groin anatomical structure, especially the Fruchauds myopectineal orifice, reinforcing the extraperitoneal space and completely covering the orifice seem to be the most effective and reasonable method for hernia repair currently.³

Many open techniques that combined the benefit of tension-free with the advantages of the extraperitoneal approach have been in use for decades. For instances, Stoppa⁴ developed his technique through a lower midline incision putting a giant prosthesis in the extraperitoneal space with good results. The Kugel and Modified Kugel methods both place the polypropylene mesh in the extraperitoneal space the posterior and anterior approaches respectively.⁵ In addition, the transinguinal preperitoneal technique (TIPP) and the Prolene hernia system (PHS) both are commonly used technique that proved to be successful.⁶

Laparoscopic repairs combine the advantages of minimal access surgery with the open extraperitoneal approach. The transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal repair(TEP) are the two most frequently-used methods. More surgeons prefer the latter for its not entering into the peritoneum.⁷ Many researches have shown that laparoscopic hernia repair may offer less postoperative pain and early return to normal activities compared with open method. However, its potential intraoperative complications, need for general anesthesia and long learning curve have restricted its use to some extent.⁸

To date, clinical comparisons between TEP and open extraperitoneal herniorrhaphy are not very abundant. There is no meta-analysis directly comparing the outcomes of laparoscopic extraperitoneal herniorrhaphy and open extraperitoneal mesh repair. In the present article, different types of open extraperitoneal repairs with prosthetic meshes are combined as they all achieve similar clinical goals.⁶

Section snippets

Literature search

All randomized controlled trials and prospective case control studies that compared TEP and the open extraperitoneal procedures for the repair of groin hernias were identified intensively in the electronic databases Pubmed, Embase, Web of Science, Medline, and the Cochrane Library from January 1992 to March 2013. The search strategies used the following major medical terms: “inguinal hernia”, “extraperitoneal”, “laparoscopic”, “OPM”, “Stoppa”, “Kugel”, “PHS”, and “repair/hernioplasty”. The

Results

The flowchart of literature selecting is presented in Fig. 1. Eventually, the meta-analysis included two well-designed comparative studies and 10 randomized controlled trials containing a total of 1157 patients (1377 hernias) older than 18 years of age.3, 4, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 The 2 comparative studies20, 21 had a large sample size, enough information and comparable baseline characteristics. Though one of them²¹ was written in French, the abstract and useful needed contents

Discussion

There is still an ongoing debate on the first line treatment for inguinal hernia. So far, there is no consensus about the best method for surgical repair.²⁶ Currently, the reinforcement of the Fruchauds myopectineal orifice in the extraperitoneal space seems to be the most logical and effective method of herniorraphy. The meshes are all placed in the extraperitoneal space and completely cover the Fruchauds orifice either through an open approach or a laparoscopic way. The open extraperitoneal

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Cited by (39)

Healthcare Resource Utilization in Inguinal Hernia Repair: A Three-Year Cost Evaluation of Truven Health Marketscan Research Databases
2021, Journal of Surgical Research
Citation Excerpt :
In both laparoscopic and open cases, mesh is typically employed to create a tension free repair. As surgeon experience has accumulated over time, primary outcomes (recurrence rates) for these different techniques are generally accepted to be similar.2-12 Given the ubiquity of the condition, efforts to minimize cost while maximizing benefit are particularly impactful when it comes to inguinal hernia repair.
Inguinal hernia repair is the most commonly performed elective operation in the United States, with over 800,000 cases annually. While clinical outcomes comparing laparoscopic versus open techniques have been well documented, there is little data comparing costs associated with these techniques. This study evaluates the cost of healthcare resources during the 90-d postoperative period following inguinal hernia repair.
We analyzed data from the Truven Health MarketScan Research Databases. Adult patients with an ICD-9 or CPT code for inguinal hernia repair from 2012 to 2014 were included. Patients with continuous enrollment for 6 mo prior to surgery and 6 mo after surgery were analyzed. Related healthcare service costs (readmission and/or ER visit and/or outpatient visit) were calculated by clinical classification software and generalized linear modeling was used to compare healthcare utilization between groups.
124,582 cases were identified (open = 84,535; lap = 40,047). Index surgery cost was 41% higher in laparoscopic cases. The cost for readmission was close to $25,000 and similar between both groups, but the laparoscopic group were 12% less likely to be readmitted for surgical complications within 90-d when compared to the open group. Cost of bilateral laparoscopic repair is less than that of serial unilateral open repairs.
Laparoscopic inguinal hernia repair carries a higher index surgery cost than open repair. However, open repair has an increased rate of readmission. To maximize value, efforts should be directed at minimizing readmissions and improving identification of bilateral hernias at the time of initial presentation.
A randomised controlled trial of Lichtenstein repair with Desarda repair in the management of inguinal hernias
2021, Annals of Medicine and Surgery
Ever since the advent of mesh hernioplasty with low recurrence rates, surgeons have turned a blind eye towards its devastating mesh related complications. Consequently, the quest for the best hernia surgery, that is as effective as the mesh repair but lacks its complications, continues.
The present study was carried out to compare the results of the Lichtenstein repair with the Desarda repair in the treatment of inguinal hernias.
A total of 77 patients with 87 hernias were randomly allocated into two groups to undergo either the Desarda repair (Group I, 39 patients with 45 hernias) or the Lichtenstein repair (Group II, Control, 38 patients with 42 hernias). 3 patients didn't complete the follow-up and were excluded from analysis. Finally, 40 hernias were analyzed in the Lichtenstein group and 44 in the Desarda group.
After a 6-month follow-up period it was found that neither of the two groups had any recurrence. The incidence of chronic inguinodynia was much higher in the Lichtenstein group as compared to Desarda group. The pain scores, mean operating time, mean time to return to work and analgesic requirement was much lower with the Desarda repair as compared to Lichtenstein repair.
Desarda repair was found to be as effective as the Lichtenstein repair in terms of recurrence and better in terms of chronic inguinodynia, complications and post operative pain scores. Desarda repair requires a significantly shorter operating time. The economic burden of this repair is much less compared to mesh repair.
Trans-gastric inguinal hernia repair using pure natural orifice transluminal endoscopic surgery
2021, Asian Journal of Surgery
Abdominal Wall Hernia
2018, Current Problems in Surgery
Citation Excerpt :
Both transabdominal totally extraperitoneal (TAPP) or TEP laparoscopic techniques have been used to address inguinal hernias beginning in the 1990s.137,138 Although patients have benefited from diminished pain and faster recovery compared to the open approach,139,140 22.5% of patients still develop chronic pain after laparoscopic inguinal hernia repair.141 Pain may be neurogenic secondary to nerve impingement or non-neurogenic from periosteal injury, both caused by the fixation device.
Defining the characteristics of certified hernia centers in Italy: The Italian society of hernia and abdominal wall surgery workgroup consensus on systematic reviews of the best available evidences
2018, International Journal of Surgery
Citation Excerpt :
Mean AMSTAR score of these papers was 6.9. Values were extracted from the 13 highest scoring studies [51–56,58–60,63–65,67,69]. Table 8 shows the characteristics of selected studies.
The terms “Hernia Center” (HC) and Hernia Surgeon” (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification.
The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion.
The Commission defined a certification process including: “FLC - First level Certification”: restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. “Second level certification”: Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. “Third level certification”: High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission.
The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.
Totally extraperitoneal laparoscopic inguinal hernia repair using a self-expanding nitinol framed hernia repair device: A prospective case series
2017, International Journal of Surgery
Citation Excerpt :
After three months, 2 (3.7%) patients experienced mild pain (VAS ≤ 2) and none of the patients reported pain after six months. Other advantages of the TEP procedure compared to open extraperitoneal mesh repair are shorter hospital stay and quicker return to normal activities or work [7]. In our study, the majority of the patients left the hospital on the day of surgery.
The use of a self-expanding nitinol framed prosthesis (ReboundHRD^®) for totally extraperitoneal laparoscopic inguinal hernia repair (TEP-IHR) could solve issues of mesh shrinkage and associated pain. We prospectively evaluated the use of the ReboundHRD^® mesh for TEP-IHR.
All patients who underwent a TEP-IHR using the ReboundHRD^® Large mesh from April 2014 till May 2015, were included. No mesh fixation was performed. Follow-up assessments were performed at the day of surgery, 1, 2, and 7 days, 1, 3, 6, and 12 months. Outcome measures include post-operative pain (visual analogue scale, VAS), operative details, complications, and recurrence rate.
In total, 69 TEP-IHR procedures were performed in 54 patients (15 bilateral hernias). No perioperative and 5 (9%) postoperative complications occurred, all graded Clavien-Dindo I-II. The median length of stay was 1 day (range 0–3), with 78% of the operations performed in an ambulatory setting. Median VAS score decreased from 3 (range 0–4) on the day of surgery to 1 (range 0–2) on day 7. Patients were completely pain-free at a median time of 5 (range 1–60) days. The majority (80.4%, 37/46) of the active patients went back to work within 2 weeks (maximum 6 weeks). At a median follow-up of 19 months (range 16–26 months), no recurrences occurred.
TEP-IHR using a self-expanding nitinol framed hernia repair device is a safe technique in longterm follow-up. The technique is associated with a low incidence of postoperative pain, a short hospital stay and quick return to normal activities.

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ReviewTotally extraperitoneal laparoscopic hernioplasty versus open extraperitoneal approach for inguinal hernia repair: A meta-analysis of outcomes of our current knowledge

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Literature search

Results

Discussion

Am J Surg

Am J Surg

Am J Surg

Int J Surg

Ann Chir

J Am Coll Surg

Surg Clin North Am

Reg Anesth Pain Med

Laparoscopic Hernia Repair Study Team. Simultaneous bilateral laparoscopic inguinal hernia repair: an analysis of 1336 consecutive cases at a single center

Surg Endosc

Laparoscopic total extraperitoneal repair versus anterior preperitoneal repair for inguinal hernia

Hernia

Reduced acute phase response after laparoscopic total extraperitoneal bilateral hernia repair compared to open repair with the Stoppa procedure

Surg Endosc

Preperitoneal groin hernia repair with Kugel patch through an anterior approach

ANZ J Surg

Laparoscopic inguinal hernia repair: transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) approach: a prospective randomized controlled trial

Surg Endosc

Comparison of the open tension-free mesh-plug, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) laparoscopic techniques for primary unilateral inguinal hernia repair: a prospective randomized controlled trial

Surg Endosc

Assessing risk of bias in included studies

A simple method for converting an odds ratio to effect size for use in meta-analysis

Stat Med

Review
Totally extraperitoneal laparoscopic hernioplasty versus open extraperitoneal approach for inguinal hernia repair: A meta-analysis of outcomes of our current knowledge