|Year : 2022 | Volume
| Issue : 1 | Page : 67-70
A prospective randomised study comparing transabdominal pre-peritoneal versus totally extra-peritoneal laparoscopic approaches for inguinal hernia repair
Satish Reddy Manda1, Sujith Philip1, CN Rajesh2, Sruthy Merry Sam3, Deepak Varma4
1 Department of Surgery, Believers Church Medical College Hospital, Thiruvalla; Department of Surgery, Medical Trust Hospital, Kochi, Kerala, India
2 Department of Surgery, Medical Trust Hospital, Kochi, Kerala, India
3 Department of Surgery, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
4 Department of Surgery, Medical Trust Hospital, Kochi, Kerala, India; Department of Surgery, Health City Cayman Islands, Grand Cayman, Cayman Islands
|Date of Submission||26-Jan-2022|
|Date of Decision||03-Mar-2022|
|Date of Acceptance||04-May-2022|
|Date of Web Publication||14-Jul-2022|
Dr. Sujith Philip
Believers Church Medical College Hospital, St Thomas Nagar, Thiruvalla - 689 103, Kerala
Source of Support: None, Conflict of Interest: None
Background: Inguinal hernia repair is one of the most common surgical procedures undertaken in routine surgical practice worldwide. Laparoscopic inguinal hernia repair has now become accepted as a standard method of treatment There are two widely accepted methods of laparoscopic inguinal hernia repair, transabdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP). Materials and Methods: Our study was a prospective randomised study to compare the outcome of both TAPP and TEP for inguinal hernia repair and included a total of 120 patients who were diagnosed to have inguinal hernia and underwent surgical management electively for the same. They were randomised into both TAPP and TEP groups and the results were compared. Results: Amongst the two groups, laparoscopic TAPP repair required more time compared to laparoscopic TEP repair. However, post-operative pain, duration of hospital stays, complication rate and return to normal work did not show any significant difference between the two groups. Conclusion: Both laparoscopic TAPP and laparoscopic TEP repair are acceptable and equally efficacious treatment choices for inguinal hernia repair.
Keywords: Inguinal hernia, totally extra-peritoneal, transabdominal pre-peritoneal
|How to cite this article:|
Manda SR, Philip S, Rajesh C N, Sam SM, Varma D. A prospective randomised study comparing transabdominal pre-peritoneal versus totally extra-peritoneal laparoscopic approaches for inguinal hernia repair. Kerala Surg J 2022;28:67-70
|How to cite this URL:|
Manda SR, Philip S, Rajesh C N, Sam SM, Varma D. A prospective randomised study comparing transabdominal pre-peritoneal versus totally extra-peritoneal laparoscopic approaches for inguinal hernia repair. Kerala Surg J [serial online] 2022 [cited 2022 Sep 24];28:67-70. Available from: http://www.keralasurgj.com/text.asp?2022/28/1/67/350902
| Introduction|| |
Laparoscopic groin hernia repair can be done by either transabdominal pre-peritoneal (TAPP) approach or totally extra-peritoneal (TEP) approach. The role of laparoscopic approach for bilateral and recurrent hernia is now very well established. The present guidelines recommend a laparoscopic approach to hernia repair even for unilateral cases. This is because of the perceived short-term benefits of a laparoscopic repair. The most commonly used laparoscopic techniques for inguinal hernia repair are TAPP repair and TEP repair. TEP is considered technically more difficult than TAPP, but may lessen the risks of damage to the internal organs and of adhesion formation, leading to intestinal obstruction, which has been linked to TAPP. Indirect comparisons between TAPP and TEP have raised questions about whether the two procedures do perform differently for some outcomes such as recurrence.
This study aims at comparing the outcome of both TAPP and TEP for inguinal hernia repair in terms of post-operative pain, operative duration, intraoperative and post-operative complications and recurrence rate at 6 months.
| Materials and Methods|| |
This was a prospective randomised study. This study consisted of 120 patients of inguinal hernia treated with laparoscopic hernia repair, 64 of whom were treated by laparoscopic TAPP mesh repair and the remaining 56 cases were treated by TEP repair of inguinal hernia. The patients were selected for the type of surgery on the day of surgery by random allocation by sealed envelope technique for sequence generation.
The inclusion criteria were all consecutive cases of unilateral, bilateral and recurrent inguinal hernias diagnosed clinically in the age group of 18–80 years on an intention-to-treat basis. Exclusion criteria were morbidly obese patients, suspicion of malignancy, complicated hernia and those having a contraindication to general anaesthesia.
The number of patients requiring treatment was chosen after calculating the incidence of adverse incidence in the unit before the study. The classification type of hernia into the eight groups was done using the modified Traditional Classification. This classification allows for accurate comparison. Difficulty of surgery was assessed by the operating surgeon at the end of the surgery as easy or difficult. Duration of surgery was from the time of incision to the last suture.
The study period was 12 months. Patients were admitted 1 day before surgery. Informed consent was taken. Preoperatively the patients were allotted into laparoscopic TEP and laparoscopic TAPP repair for inguinal hernia. The surgery was performed by one of the three surgeons involved in the trial. All patients were given cephalosporin antibiotic at induction and continued for two more doses. All procedures were performed under general anaesthesia. Standard 3-port technique was used. In TAPP, the peritoneal flap was sutured with 2 0 Polyglactin. All patients had urinary catheters introduced after induction of anaesthesia, which was removed the next day morning except in cases where there was evidence of significant prostatic hypertrophy or stenosis.
All patients were given three doses of opioid analgesic tramadol and antiemetic ondansetron, one dose immediate postoperatively and then three doses for the next 24 h and thereafter on a 'as and when' required basis. Oral feeds were started on the same day of surgery postoperatively. Patients were advised to be ambulant on the same day of surgery. Pain was measured by a Wong pain facies scale and done in the morning on the next day. The other parameters were entered during the rounds on the next day. Patients were called for review in the outpatient department on day 7, 30, 90 and 180 days after surgery.
All the data were prospectively entered into a pro forma, which was analysed at the end of the study period whereby the two groups were compared for the allocated endpoints. Unilateral and bilateral hernia were compared separately. Statistical tests included t-test, which was used for continuous and selected discrete variables and independent sample t-test to test for significance of difference between the two groups. The analysis was done using SPSS 21 (IBM-SPSS, New Delhi, India). The data were entered into the pro forma kept in patient case file.
| Results|| |
The study focused on obtaining the outcome of both TAPP and TEP for inguinal hernia repair on the basis of post-operative pain, operating time, intraoperative and post-operative complications and recurrence rate. The details are given in [Table 1]. Unilateral and bilateral groups were compared separately.
Unilateral transabdominal pre-peritoneal versus unilateral totally extra-peritoneal
The number of unilateral TAPP was 34 and that of TEP 44.
The mean duration was 92.56 min for unilateral TAPP repair and 89.32 min for unilateral TEP hernia repair (P = 0.06), and there was no significant differences. There was no significant difference between the two groups regarding the intraoperative and post-operative complications, conversion rate, pain score, number of analgesics taken, mean hospital stay, follow-up pain score, degree of neuralgia, haematoma and seroma. The mean time of ambulation was 16.44 h for unilateral TAPP and 19 h for unilateral TEP.
Bilateral transabdominal pre-peritoneal versus bilateral totally extra-peritoneal
The number of bilateral TAPP was 30 and bilateral TEP 12.
[Table 2] shows that the mean duration was 132.97 min for bilateral TAPP repair and 117.83 min for bilateral TEP hernia repair (P = 0.0296). Therefore, the mean duration was significantly higher in bilateral TAPP repair. There was no significant difference between the two groups in terms of intraoperative and post-operative complications, conversion rate, time of ambulation, pain score, number of analgesics taken, mean hospital stay, follow-up pain score, degree of neuralgia and haematoma. The mean seroma incidence was 2.34 for bilateral TAPP and 1 for TEP (P = 0.05). Thus, bilateral TAPP has higher incidence of seroma than bilateral TEP.
There were no recurrences in the unilateral TAPP or TEP arm at 6 months, while there was one recurrence each in the bilateral TEP and bilateral TAPP arm.
| Discussion|| |
This study including 64 patients undergoing laparoscopic TAPP procedure and 56 patients undergoing laparoscopic TEP procedure was undertaken to study the efficacy based on post-operative pain, duration of operation, intraoperative and post-operative complications and recurrence rate after 6 months.
Patients were aged between 18 and 80 years and age groups were comparable, similar to the other studies., Another study on inguinal hernia repair had reported that 91% of repairs were done on males and our study also shows that all patients were male. In our study, general anaesthesia was administered for all cases, similar to the other studies.
The most common type of hernia in both the groups was the direct inguinal hernia medium type or Type 4. This is similar to other studies published. Obese patients with body mass index (BMI) >30 were excluded from the study. There was no significant difference between the two groups regarding BMI.
In this study, the overall mean operative time was significantly less in bilateral laparoscopic TEP repair than in laparoscopic TAPP repair. This might have been due to the time taken to suture the peritoneal flap in TAPP.
Intraoperative complications included bleeding, surgical emphysema, peritoneal breach and injury to vas recognised during surgery. The extent of bleed was assessed by the surgeon. There was a significantly higher incidence of intraoperative complications in TEP as compared to TAPP. In most cases, it was peritoneal breach. This is different from other published studies which have found a higher incidence of intraoperative complications in TAPP. However, this may partly be due to the fact that peritoneal breach is more common during TEP. The intraoperative complication in TEP was more than that in TAPP both in unilateral and in bilateral groups.
Post-operative complication incidence was not significantly different for TAPP and TEP. Common complications were seroma and urinary retention in elderly males. The mean pain score for TAPP and TEP was not significantly different, similar to other studies. There was no significant difference between the time of ambulation in TAPP and TEP in bilateral groups. However, time of ambulation is more for unilateral TEP when compared to unilateral TAPP. There was no significant difference between the two groups regarding the number of analgesics taken, mean hospital stay, follow-up pain score and degree of neuralgia.
Seroma rate on follow-up differed in both groups. When compared overall, it was higher for TAPP. On comparing bilateral TAPP with bilateral TEP, TAPP has higher incidence of seroma than TEP. There was no significant difference in unilateral TAPP and TEP. The time to return to normal activity is highly subjective. Patients returned to their normal activities based on their pre operative level of activities and social situation existing at home. Time to return to work for TAPP and TEP was not significantly different. People take leave from work for a specified period of time and are not motivated to return to work even if they are fit to do so. Hence, this parameter is variable.
The follow-up period was for 6 months. There was a mean follow-up of 78.6% at a mean of 1-year follow-up. There were three recurrences: one in the TAPP group and two in the TEP group. All three recurrences occurred in the first 40 cases. The difference was not significant. There was one case of port site hernia in the TAPP group. There were no cases of intestinal obstruction.
The limitations of the study are the period of follow-up. However, most recurrences due to technical issues occur during the first 6 months of the surgery. Although the number of patients accrued was calculated according to the formula mentioned earlier, larger number of patients would have had more applicability.
| Conclusion|| |
Our study supports the view that laparoscopic TAPP and TEP repair for inguinal hernia are safe and efficacious. Laparoscopic TAPP repair required more time compared to laparoscopic TEP repair when bilateral. There was no significant difference between these two methods of in terms of post-operative pain, duration of hospital stay and complication rate. The incidence of seroma was higher for bilateral TAPP as compared to bilateral TEP. Both methods of laparoscopic inguinal hernia repair are comparable as regard to pain and recurrence rates. Both techniques are acceptable treatment options for inguinal hernia repair.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Köckerling F, Simons MP. Current concepts of inguinal hernia repair. Visc Med 2018;34:145-50.
Laupacis A, Sackett DL, Roberts RS. An assessment of clinically useful measures of the consequences of treatment. N Engl J Med 1988;318:1728-33.
Zollinger RM Jr. A unified classification for inguinal hernias. Hernia 1999;3:195-200.
Swanstorm LL. Laparoscopic herniorrhaphy. Surg Clin N Am 1996;76:483.
Primatesta P, Goldacre MJ. Inguinal hernia repair: Incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835-9.
Krishna A1, Misra MC, Bansal VK, Kumar S, Rajeshwari S, Chabra A. Laparoscopic inguinal hernia repair: Transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) approach: A prospective randomized controlled trial. Surg Endosc 2012;26:639-4.
[Table 1], [Table 2]