Study of Selection of Method of Laparoscopic Inguinal Hernia Repair by Comparison of Totally Extraperitoneal with Transabdominal Preperitoneal

Inclusion Criteria

• Patients having uncomplicated reducible and nonobstructive unilateral and bilateral inguinal hernias.

• Patients with primary and recurrent hernias.

• Patients should be operated under general anesthesia.

Exclusion Criteria

• Patients presented with irreducible/strangulated/obstructed inguinal hernia who required emergency exploration.

• Pediatric age group (<12 years) patients are not included.

• High-risk patients (ASA grade >3) who are not fit for general anesthesia.

• Patients who were not willing to follow-up.

• History of any previous pelvic surgery or irradiation for malignancy.

• Recurrent laparoscopic hernia.

Visual analog scale (VAS) was used to assess the severity of pain. The patient was asked to describe the pain on a scale of 0–10; 0 denoted “no pain,” 1 denoted “mild pain,” and 10 denoted “worst pain.”

Pain Score

• P0, VAS score 0: No pain

• P1, VAS score 1–3: Mild

• P2, VAS score 4–6: Moderate

• P3: VAS score 7–10: Severe

Age

In our study, the maximum age of the patients at the time of operation was 68 years and the minimum age was 16 years. The highest age group was between 45 and 64 years. In a study by Rutkow and Robbins,² the age at presentation is discussed as follows. It is compared with this study (Table 12).

In the study of Rutkow and Robbins, the highest incidence was in the age group 45–64 years, which was in 30 cases. In our study, 26 cases in the 45–64 age group were the highest cases. The age incidence of our study matches the above study. In our study, the average mean age is 45.40. The mean average age 55.98 ± 12.71 was found in the study by Choi et al.³

Laparoscopic inguinal hernia repair is done under general anesthesia whereas open inguinal hernia repair is usually done under local or spinal anesthesia. So, in elderly patients who are usually comorbid, the laparoscopic procedure becomes riskier, making it a disadvantage of the laparoscopic procedure. Laparoscopic hernia repair is an ideal procedure in young and in non-comorbid elderly patients. In TEP, there is the formation of pneumo-preperitoneal space creation is done while in TAPP pneumoperitoneum is created so in conditions in which pneumoperitonem is contraindicated we can still go for TEP.

Types of Hernia

In our study, the average percentage of incidence of direct hernia was 58% while for indirect hernia it was 42%, and the mean age group in our study was 45.40 years. That is because older patients have more chance to develop direct hernia rather than indirect hernia. The incidence of different types of hernia in our study is consistent with the analysis of the hernia centers 8-year series of 2,861 primary hernias (Table 13).

Types of Surgery

In this study, 50 cases underwent TEP repair and 50 cases underwent TAPP (Table 14). The patients were randomly chosen for the different surgeries.

Laparoscopic TEP repair is technically more difficult than laparoscopic TAPP repair. In TAPP pneumoperitoneum is created and later peritoneal flap dissection is done. It is the lucid procedure as compared to the dissection of preperitoneal space by balloon inflation in TEP. According to the basic principles of laparoscopic surgery, in the TEP procedure, there is no triangulation of ports, which makes it a challenging procedure.

It is advisable to repair a recurrent hernia previously operated by open repair, by the laparoscopic method as a smaller number of adhesions are encountered and a smaller number of additional defects are missed. One of our patients, who was operated by an open Lichtenstein repair method 3 years ago, developed recurrence. He was easily managed for recurrent hernia by TAPP procedure.

Duration of Surgery

In our study, the time for laparoscopic inguinal hernia repair (TEP/TAPP) was 90 minutes compared to the Udwadia Tehemton study which was taking around 67.5 minutes.⁴ In the medical research council (MRC) trial, the operating time was 58.4 minutes for the laparoscopic inguinal hernia repair group (Table 15).

This may be due to the difficult initial learning curve in laparoscopic hernia repair. The time taken to perform laparoscopic repair also depends on the type of hernia (direct/indirect) and size of the defect. Encircling the cord in laparoscopic indirect inguinal hernia repair is challenging as compared to direct inguinal hernia repair, therefore requiring more time in indirect hernias. In laparoscopic TEP repair, there is the possibility of an accidental tear in the peritoneum. It can cause seepage of carbon dioxide into the abdominal cavity. This decreases the working preperitoneal space. Also, repair of the peritoneal tear has to be done. This can increase the operative time for TEP repair in such cases.

In our study, there were 12 cases of bilateral direct inguinal hernia repair done laparoscopically. For bilateral inguinal hernias repair, TEP is simple because there is the creation of common preperitoneal space for repair on both sides by balloon. Whereas in TAPP, different peritoneal flaps have to be made. This is proven by our study, as the average time taken for bilateral TEP was 100 minutes, and for TAPP was 140 minutes.

Intraoperative Complications

Laparoscopic hernia repair can be faced with serious intraoperative complications (Table 16). When laparoscopic hernia was newly developed these complications were encountered more often, but it was due to the lack of the number of surgeries performed with this method and hence experience was minimal. Few studies and trials showed common injuries during laparoscopic surgeries; according to the MRC trial,⁵ three complications were common during TAPP surgeries, which were bladder injury, lateral femoral cutaneous nerve injury, and common iliac artery injury. About 15 visceral and vascular injuries were reported in TAPP repair by the laparoscopic group of the European Union Hernia Trialists Collaboration. Two bladder injuries were reported while performing TAPP during the clinical study (SCUR).⁶ Vascular injuries of 0.42% and visceral injuries of 0.11% were reported in the study of Brittner et al. 2011. As mentioned previously, due to lack of exposure to such surgeries, herniation of small bowel loops through incomplete sheath closure at the port site causing obstruction that occurred more often, but they were gradually recognized and with sheath closure compulsorily performed their incidence has decreased.

In our study, there were no major complications such as major vascular injury, or visceral injury in laparoscopic inguinal hernia repair. These major complications are not usually witnessed in open inguinal hernia repair surgeries as there is no dissection in deeper planes in open inguinal hernia repair surgeries.

Other unique complications of laparoscopic surgeries are port site hernias, hemorrhage due to injury to epigastric and gonadal vessels, hypotension, hypercapnia, and subcutaneous emphysema.

Minor intraoperative complications such as subcutaneous emphysema were encountered in 24% of cases of TEP, and it was never found in TAPP repair. Surgical emphysema was noted in 48% patients of bilateral TEP repair and 56% patients of pneumoperitoneum due to peritoneal breach encountered in a study by Philips et al. Pneumoperitoneum was easily managed by insertion of Veres needle at Palmer’s point or repair of the peritoneal rent. No active management is required for subcutaneous emphysema. It usually resolves with time.

Postoperative Complications

In our study, the postoperative complications such as hematoma, seroma, wound infection, scrotal edema, urinary retention, and shoulder pain were reported in 0, 4, 2, 2, 0, and 4% cases in the laparoscopic hernia repair group (Table 17).

In the study done by Tehemton et al. wound infection rates were significantly lower after laparoscopic techniques (1%). Also, a surgical site infection (SSI) of 0.6–1.5% was observed by McCormack et al.⁷ and Schmedt et al. in the laparoscopic method. Our study has comparable results with the above study regarding wound infection. Wound infection at the port site is managed with regular cleaning and dressing. One of the advantages of laparoscopic hernia repair is decreased incidence of SSI. A single shot of preoperative antibiotic can drastically lower the chances of postoperative SSI. Probable causes of SSI were high volume centers, not maintaining proper aseptic and antiseptic protocols, local site skin infections, lack of hygiene, and lack of usage of postoperative antibiotics. in our study, 2% of cases operated by TAPP developed port site infection most probably due to missed intraperitoneal infection. It is less in TEP as we remain outside the peritoneum while performing surgery and the peritoneum act as a barrier for infection to reach the port side.

In our study, no incidence of hematoma was recorded. In the study done by Tehemton et al., the incidence of inguinal hematoma was found to be significantly lower after the laparoscopic repairs (13.1%). McCormack et al. encountered 8.7% hematoma; Schmedt et al. found hematoma in 13.1%. Contrary to this, Phillips et al. had 0% hematoma in their patients. The incidence of hematoma formation in laparoscopic repair is comparatively low.

In our study, 4% of laparoscopic hernia repair patients develop seroma. In a study done by Tehemton et al., seroma formation was observed in (10%) by laparoscopic techniques. This shows that there is an increased incidence of seroma in laparoscopic repair, making it a disadvantage. The reason is, increase dissection is required in laparoscopic repair either to make preperitoneal space or to make the peritoneal flap. In our observation low incidence is mainly due to meticulous dissection during surgery, packing with gauze pieces at the hernial defect site, and strapping with dynaplast to decrease the potential space for seroma collection. We can also prevent seroma formation by tucking pseudosac to the posterior abdominal wall with tacker and decreasing the potential space for seroma formation. We observed more seroma formation in TAPP which is about 3% out of the 4% of indirect hernia patients in our study mainly because of excessive dissection and pulling of the indirect hernial sac from the deep ring making it difficult to do hemostasis beyond deep ring which may be the cause. No active management is required for seroma. The seroma usually subsides within a month. We advise never to aspirate the seroma as it may introduce infection from outside into the seroma.

A total of 2% of our patients developed scrotal edema postoperatively in TAPP, and none of our TEP patients had developed scrotal edema. Mainly observed in patients with large complete indirect hernial defects; as such defects require excessive dissection and mobilization and the indirect sac can be dissected more meticulously by TEP as compared to TAPP according to our experience. No active management is required. The edema usually subsides within a month. We have prescribed chymotrypsin–trypsinogen and serratiopeptidase combination for oedema treatment.

In our study, 4% of the cases experienced shoulder pain in TAPP, which may be due to diaphragmatic irritation caused by carbon dioxide insufflation to create pneumoperitoneum, and this minor complication is never faced in TEP as pneumo preperitoneum is created rather than pneumoperitoneum.

Mesh infection is also a troublesome complication that requires the removal of the mesh. Mycobacterium other than tuberculosis (MOTT) can be cultured from infected mesh. Luckily, we did not encounter this kind of complication in our study because the mesh and mesh fixation devices used were sterilized by ethyline oxide sterilisation (ETO), and we usually take laparoscopic hernia as the first operation in our operative list to prevent infection.

Postoperative Pain

In our study, postoperative pain at 1 week of surgery was 26% which was of mild grade that is P1 according to VAS score in both TEP and TAPP laparoscopic repair method. No significant difference was found according to the SCUR trial for graded pain scores on the 7-day postoperative visit. During this visit, 72% of patients in the laparoscopic group, reported no pain. The veterans affairs (VA) trial found significantly less pain on the day of the operation and at 2 weeks in both TEP and TAPP methods by using a VAS.

Chronic pain is sometimes a debilitating complication for the patient and a more difficult problem for the surgeon to treat than perioperative pain and also the spectrum of severity is wide. Hence, this makes it more important for successful inguinal hernia repair.

In our study, postoperative pain at 3 months of surgery was found in only two patients (2%) in TAPP cases for which we could not find any reasons. None of our TEP patients had postoperative pain post 3-months follow-up. The laparoscopic group in the MRC trial, at 1 year after the operation, had a significantly lower rate of persistent groin pain. In the VA trial, incidence of neuralgia or other pain post 1 year after the operation was 9.8% in the laparoscopic group. Significantly a smaller number of cases of pain persisting post 1 year of either surgery was found according to The European Union meta-analysis.⁸

Hence, there is evidence as per our study that laparoscopic surgeries show significant differences in both postoperative and persistent pain.

Recurrence

In our study, we found 0% recurrence in laparoscopic hernia repair cases. MRC laparoscopic hernia trial group found a 1.9% recurrence rate in the laparoscopic group. Results of recurrence are comparable for both TEP and TAPP in our study (Table 18). The most common reason for recurrence is improper dissection and separation of the hernial sac which might cause its inadequate reduction or other additional defects or hernias may be missed.⁹ Incomplete mesh placement as in not covering the defect completely, the small size of mesh or not taking into account the contraction of mesh is another major reason for recurrence. It is now generally believed that the mesh size should be at least 10 cm × 14 cm¹⁰ to cover all of the potential hernia sites, to provide at least 4-cm overlap with the hernia, and to avoid problems with mesh migration, shrinkage, and rolling. We kept 12 cm × 15-cm-sized mesh in both TEP and TAPP.

Duration of Hospital Stay

The mean duration of the hospital was found to be 2.17 days for the laparoscopic inguinal hernia repair. Since ours is a teaching institution the minimum time taken from admission to surgery is around 1 day hence making the duration of stay apparently longer. Choi et al.³ had a mean hospital stay of 1.4 days for the laparoscopic method. Similarly, Phillips et al. in their study found a mean stay of 1.91 days for the laparoscopic method. This shows, there is decreased hospital stay in laparoscopic surgery. The mean duration of hospital stay in our study for TEP was 2.1 and for TAPP was 2.24. it is showing no major difference in hospital stay for TEP vs TAPP.

Cost of Surgery

The increased cost of surgery is a major drawback of laparoscopic hernia repair, and this increased cost is due to more expensive equipment, longer operative time, and more operative charges claimed by surgeons. Accurate evaluation of operative cost based on the type of procedure (TEP/TAPP), type and length of anesthesia, and the number of tackers used to fix the mesh. Laparoscopic instruments require a special sterilization technique (ETO), which also increases the cost. In the case of TAPP if the peritoneum flap is closed by the tackers, then as compared to TEP cost of surgery increases, and if the peritoneum flap is closed by intracorporeal suturing then the length of surgery will increase so in this domain TEP is better compared to TAPP.