The purpose of this study was to describe the rationale and design of a randomized controlled trial analyzing the effects of mesh type (Ultrapro versus Prolene mesh) on postoperative pain and well-being following an endoscopic Totally Extraperitoneal (TEP) repair for inguinal hernias (short: TULP trial).
Methods and design
The TULP trial is a prospective, two arm, double blind, randomized controlled trial to assess chronic postoperative pain and quality of life following implantation of a lightweight (Ultrapro) and heavyweight (Prolene) mesh in endoscopic TEP hernia repair. The setting is a high-volume single center hospital, specializing in TEP hernia repair. All patients are operated on by one of four surgeons. Adult male patients (≥18 years of age) with primary, reducible, unilateral inguinal hernias and no contraindications for TEP repair are eligible for inclusion in the study. The primary outcome is substantial chronic postoperative pain, defined as moderate to severe pain persisting ≥ 3 months postoperatively (Numerical Rating Scale, NRS 4–10). Secondary endpoints are the individual development of pain until three years after the TEP procedure, the quality of life (QoL), recurrence rate, patient satisfaction and complications.
Large prospective randomized controlled studies with a long follow-up evaluating the incidence of chronic postoperative pain following implantation of lightweight and heavyweight mesh in endoscopic (TEP) hernia repair are limited. By studying the presence of pain and quality of life, but also complications and recurrences in a large patient population, a complete efficiency and feasibility assessment of both mesh types in TEP hernia repair will be performed.
The TULP study is registered in the Dutch Trial Register (NTR2131)
Endoscopic hernia repair; TEP; Mesh; Chronic postoperative pain; Quality of life
Hernia repair after recurrence is a challenging procedure, and many approaches have been suggested for it. Total extraperitoneal (TEP) hernia repair should be considered in recurrent hernia. This study was conducted for the purpose of investigating the clinical usefulness of laparoscopic TEP hernia repair for recurrent inguinal hernia.
Among the 191
patients who underwent TEP hernia repair at these authors' center from June 2006 to January 2010, the bilateral-hernia cases and the patients with a history of previous pelvic surgery were excluded. A total of 19 patients (12.5%) were enrolled in the recurrent-inguinal-hernia group (group R), and 133 patients (87.5%) in the primary-hernia group (group P). Data were investigated retrospectively, based on the medical records.
The mean operation time was 97 minutes in group R and 99 minutes in group P (>0.05). In group R, no operation modality change occurred, and temporary urinary retention was developed in four patients (21.1%). In group P, on the other hand, operation modality change from TEP to the transabdominal preperitoneal approach was necessary in four patients (3%). Additionally, in group P, 30 patients (22.6%) had temporary urinary retention and six (4.5%) had testicular edema. No recurrence was identified during the follow-up period in both groups (mean follow-up period: 15.8 months for group R and 18.0 months for group P).
Laparoscopic TEP hernia repair seems to be a safe and useful method for correcting recurrent inguinal hernia.
Recurrent inguinal hernia; Laparoscopy; Total extraperitoneal approach
Many studies have reported that laparoscopic total extraperitoneal (TEP) repair for recurrent inguinal hernia after an open hernioplasy was safe and effective. This study was conducted to evaluate TEP repair for recurrent inguinal hernia through a retrospective analysis of our data.
Materials and Methods
We performed a retrospective analysis of the medical records of patients who were scheduled for laparoscopic TEP repair from December 2000 to December 2008. A total of 1065 cases of laparoscopic TEP repairs were performed for 944 patients by a single surgeon, and 100 cases of recurrent inguinal hernias were enrolled.
The mean operation time was longer in the recurrent hernia group than that in the primary hernia group (P < 0.001), and peritoneal tearing occurred more frequently in the recurrent hernia group (P < 0.001). Direct hernia was more frequent in the recurrent hernia group (P < 0.001). The mean number of hospital days and complications, such as seroma and postoperative pain, were similar in both groups. Three cases of recurrence occurred (0.28%): 2 occurred in the recurrent hernia group (2%) and the other occurred in the primary hernia group (0.1%).
Laparoscopic TEP repair is safe and effective for treating recurrent inguinal hernia after an open hernioplasty, because the recurrence rate was low (2%) and other complications were similar for both groups. Direct inguinal hernia was more frequent in patients who had recurrent inguinal hernia.
Endoscopic inguinal hernia repair was introduced in the Netherlands in the early 1990s. The authors’ institution was among the first to adopt this technique. In this study, long-term hernia recurrence among patients treated by the total extraperitoneal (TEP) approach for an inguinal hernia is described. A cohort study was conducted.
Between January 1993 and December 1997, 346 TEP hernia repairs were performed for 318 patients. After a mean follow-up period of 13-years, a senior resident examined each patient. An experienced surgeon subsequently examined the patients with a diagnosis of recurrent hernia. Data were collected on an intention-to-treat basis, meaning that conversions were included in the analysis. Univariant tests were used to analyze age older than 50 years, chronic obstructive pulmonary disease, body mass index, smoking habit, hernia type, history of open hernia repair, conversion, and surgeon as potential risk factors.
The analysis included 191 patients (62%) with 213 hernias. Of the original 318 patients, 59 patients died, and 68 were lost to follow-up evaluation. Perioperatively, 105 lateral, 55 medial, and 53 pantalon hernias were observed. Of the 213 hernias, 176 were primary and 37 were recurrent. The overall recurrence rate was 8.9% (8.5% for primary and 10.8% for recurrent hernias). Of the total study group, 48% of the patients experienced a bilateral inguinal hernia during their lifetime. No predicting factor for recurrent hernia could be identified.
The current long-term results for TEP repair of primary and secondary inguinal hernia show an overall recurrence rate of 8.9%, which is slightly higher than in previous studies. The thorough examination at follow-up assessment, the learning curve effect, and the intention-to-treat-analysis may have influenced the observed recurrence rate. Also, the percentage of bilateral hernias was higher than known to date. Therefore, examination of the contralateral side should be standard procedure.
Bilateral hernia; Endoscopic hernia repair; Inguinal hernia; Long term; Recurrence rate; TEP
A minilaparoscopic combined approach for inguinal hernia appears to be safe and feasible for a more simple endoscopic hernia repair.
Endoscopic surgical repair of inguinal hernia is currently conducted using 2 techniques: the totally extraperitoneal (TEP) and the transabdominal (TAPP) hernia repair. The TEP procedure is technically advantageous, because of the use of no mesh fixation and the elimination of the peritoneal flap, leading to less postoperative pain and faster recovery. The drawback is that TEP is not performed as frequently, because of its complexity and longer learning curve. In this study, we propose a hybrid technique that could potentially become the gold standard of minimally invasive inguinal hernia surgery. This will be achieved by combining established advantages of TEP and TAPP associated with the precision and cosmetics of minilaparoscopy (MINI).
Materials and Surgical Technique:
Between January and July 2011, 22 patients were admitted for endoscopic inguinal hernia repair. The combined technique was initiated with TAPP inspection and direct visualization of a minilaparoscopic trocar dissection of the preperitoneum space. A10-mm trocar was then placed inside the previously dissected preperitoneal space, using the same umbilical TAPP skin incision. Minilaparoscopic retroperitoneal dissection was completed by TEP, and the surgical procedure was finalized with intraperitoneal review and correction of the preperitoneal work.
The minilaparoscopic TEP-TAPP combined approach for inguinal hernia is feasible, safe, and allows a simple endoscopic repair. This is achieved by combining features and advantages of both TAPP and TEP techniques using precise and sophisticated MINI instruments. Minilaparoscopic preperitoneal dissection allows a faster and easier creation of the preperitoneal space for the TEP component of the procedure.
Microlaparoscopy; Minimally invasive; Needlescopic; Microlaparoscopic; Inguinal hernia
To compare the outcomes between laparoscopic total extraperitoneal (TEP) repair and prolene hernia system (PHS) repair for inguinal hernia.
A retrospective analysis of 237 patients scheduled for laparoscopic TEP or PHS repair of groin hernia from 2005 to 2009 was performed.
The mean age was 52.3 years in TEP group and 55.7 years in PHS group. Of 119 TEP cases, 98 were indirect inguinal hernia, 15 direct type, 5 femoral hernia and 1 complex hernia; Of 118 PHS cases, 100 indirect, 18 direct type. All in TEP group were performed under general anesthesia and 64% of PHS group were performed under spinal or epidural anesthesia. Preoperatively, 10 cases of recurrent inguinal hernia were involved in our study (4 in TEP, 6 in PHS group). The mean operative time was similar in both groups (74.8 in TEP, 71.2 in PHS group), however mean hospital stay (1.6 days in TEP, 3.2 days in PHS group, P = 0.018) and mean usage of analgesics (0.54 times in TEP, 2.03 times in PHS group, P < 0.01), complications (36 cases in TEP, 6 cases in PHS group, P < 0.01) showed statistical differences. There is only 1 case of postoperative recurrence inguinal hernia in PHS group but it has no statistical significance (P = 0.314).
Compared to PHS repair, laparoscopic TEP repair has some advantages; shorter hospital stay, less frequent need of analgesics; as well as more postoperative complications such as hematoma, seroma, scrotal swelling.
Inguinal hernia; Laparoscopy; Surgical mesh
Long-term data on chronic pain after endoscopic total extraperitoneal (TEP) hernia repair are hardly available.
Between January 1997 and December 1998, 416 patients with consecutive primary and recurrent inguinal hernia underwent endoscopic TEP hernia repair. Long-term follow-up evaluation was carried out from June 2007 to June 2008. The primary outcome measure was persistent pain and discomfort interfering with daily activity.
The overall response rate was 66% (273 of 416 patients). Of the 416 patients, 85 (20%) had died of causes unrelated to hernia repair and 58 (14%) were lost to follow-up. A total of 177 patients were physically examined in the outpatient clinic. Because 96 patients were not able to visit the outpatient’ clinic, they completed the survey by telephone. The median follow-up period was 10 years (range, 9–11 years). After TEP repair, 16 patients (6%) reported chronic groin pain, and 10 patients (4%) still experience pain at this writing after the 10-year follow-up period. One of the patients has experienced persistent pain and discomfort interfering with daily activity. Patients with preoperative pain have reported significantly more chronic pain (P = 0.03).
Chronic groin pain after TEP repair of primary and recurrent inguinal hernia seems to have a low incidence after a 10-year follow-up period.
Chronic pain; Endoscopic; Inguinal hernia; Long-term follow-up; TEP
The Stoppa technique for abdominal wall hernia repair was found to be an effective rescue procedure for difficulties arising during laparoscopic totally extraperitoneal inguinal hernia repair.
Background and Objectives:
Conversion to open surgery is an important problem, especially during the learning curve of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.
Here, we discuss conversion to the Stoppa procedure during laparoscopic TEP inguinal hernia repair. Outcomes of patients who underwent conversion to an open approach during laparoscopic TEP inguinal hernia repair between September 2004 and May 2010 were evaluated.
In total, 259 consecutive patients with 281 inguinal hernias underwent laparoscopic TEP inguinal hernia repair. Thirty-one hernia repairs (11%) were converted to open conventional surgical procedures. Twenty-eight of 31 laparoscopic TEP hernia repairs were converted to modified Stoppa procedures, because of technical difficulties. Three of these patients underwent Lichtenstein hernia repairs, because they had undergone previous surgeries.
Stoppa is an easy and successful procedure used to solve problems during TEP hernia repair. The Lichtenstein procedure may be a suitable option in patients who have undergone previous operations, such as a radical prostatectomy.
Totally extraperitoneal hernia repair; Conversion; Stoppa
Lichtenstein's technique is considered the reference technique for inguinal hernia repair. Recent trials suggest that the totally extraperitoneal (TEP) technique may lead to reduced proportions of chronic pain. A systematic review evaluating the benefits and harms of the TEP compared with Lichtenstein's technique is needed.
The review was performed according to the ‘Cochrane Handbook for Systematic Reviews’. Searches were conducted until January 2012. Patients with primary uni- or bilateral inguinal hernias were included. Only trials randomising patients to TEP and Lichtenstein were included. Bias evaluation and trial sequential analysis (TSA) were performed. The error matrix was constructed to minimise the risk of systematic and random errors. Thirteen trials randomized 5404 patients. There was no significant effect of the TEP compared with the Lichtenstein on the number of patients with chronic pain in a random-effects model risk ratio (RR 0.80; 95% confidence interval (CI) 0.61 to 1.04; p = 0.09). There was also no significant effect on number of patients with recurrences in a random-effects model (RR 1.41; 95% CI 0.72 to 2.78; p = 0.32) and the TEP technique may or may not be associated with less severe adverse events (random-effects model RR 0.91; 95% CI 0.73 to 1.12; p = 0.37). TSA showed that the required information size was far from being reached for patient important outcomes.
TEP versus Lichtenstein for inguinal hernia repair has been evaluated by 13 trials with high risk of bias. The review with meta-analyses, TSA and error matrix approach shows no conclusive evidence of a difference between TEP and Lichtenstein on the primary outcomes chronic pain, recurrences, and severe adverse events.
The ultrasound-guided transverse abdominis plane block (TAPB) reduces postoperative pain after laparoscopic abdominal surgery. But, its effect post laparoscopic totally extraperitoneal hernia repair (TEP) is not clear. In this study, we evaluated the analgesic effect of ultrasound-guided TAPB in TEP.
In this prospective, randomized study, forty adult patients (ASA I-II) scheduled for a TEP under general anesthesia were studied. In the TAPB group (n = 20), an ultrasound-guided bilateral TAPB was performed with 0.375% ropivacaine 15 ml on each side after the induction of general anesthesia. The control group (n = 20) did not have TAPB performed. Fentanyl 50 µg was repeatedly injected as per the patient's request in the recovery room. Pain scores at rest and on coughing were assessed postoperatively in the recovery room (20 min, at discharge) and at 4, 8, and 24 hours after surgery.
In the recovery room, pain scores (numeric rating scale, 0-10) at postoperative 20 min were lower in the TAPB group (3.9 ± 1.6, 4.9 ± 1.8) than the control group (6.9 ± 1.6, 8.0 ± 1.6) at rest and on coughing. Also, pain scores upon discharge from the recovery room were lower in the TAPB group (3.2 ± 1.2, 4.2 ± 1.5) than the control group (5.3 ± 1.6, 6.5 ± 1.8) at rest and on coughing.
The ultrasound-guided TAPB in patients that had undergone TEP reduced postoperative pain scores and the fentanyl requirement in the recovery room. Also, pain scores on coughing were reduced until postoperative 8 hours.
Herniorrhaphy; Laparoscopy; Ropivacaine; Transverse abdominis plane block; Ultrasonography
In the early 1990's laparoscopic hernioplasty gained popularity worldwide. Thereafter, laparoscopic surgeons have attempted to improve cosmesis using single port surgery. This study aims to introduce and assess the safety and feasibility of single port laparoscopic total extraperitoneal (TEP) hernia repair with a nearly-scarless umbilical incision.
Sixty three single port laparoscopic TEP hernia repairs were performed in sixty patients from June 2010 to March 2011 at Incheon St. Mary's Hospital, with the use of a glove single-port device and standard laparoscopic instruments. Demographic and clinical data, intraoperative findings, and postoperative course were reviewed.
Of the 63 hernias treated, 31 were right inguinal hernias, 26 were left inguinal hernias and 3 were both inguinal hernias. There was one conversion to conventional three port laparoscopic transabdominal preperitoneal hernioplasty. Mean operative time was 62 minutes (range, 32 to 150 minutes). There were no intraoperative complications. Postoperative complications occurred in two cases (wound seroma and urinary retension) and were successfully treated conservatively. Mean hospital stay was 2.15 days.
port laparoscopic TEP hernia repair is safe and feasible. Umbilical incision provides an excellent cosmetic outcome. Prospective randomized studies comparing single port and conventional three port laparoscopic TEP repairs with short-term outcome and long-term recurrence rate are needed for confirmation.
Single port; SILS; LESS; TEP; Inguinal hernia
Totally extraperitoneal (TEP) endoscopic hernia surgery is increasingly popular since it is associated with little postoperative pain and with early return to work. Previous appendectomy may preclude preperitoneal dissection in patients with right-sided hernias. The feasibility of TEP surgery in these patients was the subject of the present study.
Between January 2005 and February 2007 all consecutive patients undergoing TEP surgery were included in a prospective cohort study. The study group consisted of patients with right-sided and bilateral hernias. Operative times, conversions, complication rates, and return to daily activities were recorded. Patients were divided into two groups according to previous appendectomy.
A total of 462 patients with right-sided hernias underwent TEP surgery: 421 patients without previous abdominal surgery (group 1) and 41 patients with previous appendectomy (group 2). The conversion rate was significantly higher in group 2: four patients (10%) were converted to open Lichtenstein repair versus five (1%) in group 1 (p = 0.005). However, we found no significant differences in complication rate, operative time, and return to daily activities.
A right-sided (or bilateral) TEP procedure may be performed safely in patients after previous appendectomy. Despite a higher conversion rate, the vast majority of patients can be operated endoscopically.
TEP; Previous surgery; Appendectomy
Laparoscopic totally extraperitoneal (TEP) repair has been accepted as a popular procedure for inguinal hernia repair, but surgeons still encounter technical difficulties owing to unfamiliar pelvic anatomy and limited working space. We sought to estimate the learning curve for laparoscopic TEP repair without supervision.
We retrospectively analyzed the medical records of patients scheduled for laparoscopic TEP repair of an inguinal hernia from December 2000 to October 2007.
We reviewed medical records for 700 patients. The cases were divided into 8 groups: 20 patients each in groups I–V and 200 patients each in groups VI–VIII. No significant difference in demographic characteristics was identified among the groups. The mean duration of surgery significantly decreased (p < 0.001) in relation to experience; it reached a plateau of less than 30 minutes (mean 28 min) after 60 cases. The mean length of stay in hospital was 0.97 days, reaching a plateau after 20 cases. Six patients were converted to other techniques: 1 patient each in groups III and VIII and 4 patients in group VII. Three recurrences were detected; however, 2 were excluded because the patient had bilateral inguinal hernias.
We estimate the learning curve for laparoscopic TEP repair is 60 cases for a beginner surgeon. The presence of an experienced supervisor during the first 60 cases can help prevent unnecessary complications and shorten the duration of surgery.
Favourable short-term results, with respect to less postoperative pain and earlier return to physical activity, have been demonstrated with laparoscopic totally extraperitoneal (TEP) hernia repair compared with open mesh repair. However, there is limited data regarding long-term results.
PATIENTS AND METHODS
The study cohort consisted of 275 consecutive patients undergoing TEP repair between 1996 and 2002. Patient demographics, details of surgery, postoperative complications, recurrence and chronic pain were collected from patient records and from a prospective database. All patients were seen at 6 weeks and then annually for 5 years following surgery.
A total of 430 repairs were performed in the 275 patients (median age, 56 years; range, 20–94 years; men, 97.5%). Bilateral repair was performed in 168 patients (61.1%) and recurrent hernia repair in 79 patients (28.7%). Two patients were converted to an open procedure. Five-year follow-up was achieved in 72% of patients. Eleven patients (4%) died during the follow-up period due to unrelated causes. Hernia recurrence rate at 5 years was 1.1% per patient (three repairs). Recurrences were noted at 7 months, 2 years and 4 years following surgery. Chronic groin pain was reported by 21 patients (7.6%), seven of whom required referral to the pain team.
TEP hernia repair is associated with a recurrence rate of 1% at 5 years in this series. Chronic groin symptoms are also acceptably few. This recurrence rate following TEP repair compares extremely favourably with open mesh repair, particularly as it includes a high proportion of recurrent repairs. As well as the proven early benefits, TEP repair can be considered a safe and durable procedure with excellent long-term results.
Inguinal hernia; Laparoscopic surgery; Follow-up studies
Fixation of the mesh during laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is thought to be necessary to prevent recurrence. However, mesh fixation may increase postoperative pain and lead to an increased risk of complications. We questioned whether elimination of fixation of the mesh during TEP inguinal hernia repair leads to decreased postoperative pain or complications, or both, without an increased rate of recurrence.
A randomized prospective single-blinded study was carried out in 40 patients who underwent laparoscopic TEP inguinal hernia repair with (Group A=20) or without (Group B=20) fixation of the mesh.
Patients in whom the mesh was not fixed had shorter hospital length of stay (8.3 vs 16.0 hours, P=0.01), were less likely to be admitted to the hospital (P=0.001), used less postoperative narcotic analgesia in the PACU (P=0.01), and were less likely to develop urinary retention (P=0.04). No significant differences occurred in the level of pain, time to return to normal activity, or the difficulty of the operation between the 2 groups. No hernia recurrences were observed in either group (follow-up range, 6 to 30 months, median=19).
Elimination of tack fixation of mesh during laparoscopic TEP inguinal hernia repair significantly reduces the use of postoperative narcotic analgesia, hospital length of stay, and the development of postoperative urinary retention but does not lead to a significant reduction in postoperative pain. Eliminating tacks does not lead to an increased rate of recurrence.
Hernia; Urinary retention; Endoscopic; TEP; Laparoscopic
Background. Relaparoscopic treatment of inguinal hernia recurrences has become a relatively new concept with favourable results. The purpose of this study was to examine a series of relaparoscopic repair, present technical experiences, and the clinical outcomes in this subset of patients. Patients and Methods. The medical records of five patients who underwent relaparoscopic repair (TAPP or TEP) for a recurrence between March 2005 and September 2012 were retrospectively reviewed. Results. All the patients were male with a mean age of 45 years. Technical failures in the previous repairs were the main factors contributing to recurrences. In two re-TEP cases with no previous mesh fixation, the old mesh remained on the peritoneal side during preperitoneal dissection and this greatly facilitated surgical manipulation. The mean operative time was 93 min (range, 45–120 min). There were no conversions, no intraoperative complications, and no morbidity or rerecurrence after a mean follow-up period of 17 months (range, 7–24 months). Conclusion. Relaparoscopic repair appears to be safe and effective in the treatment of recurrent inguinal hernia and repeated TEP could be a simpler approach than expected in the presence of no prior mesh fixation.
Anterior open treatment of the inguinal hernia with a tension-free mesh has reduced the incidence of hernia recurrence. The Lichtenstein procedure is the current reference technique for inguinal hernia treatment. Chronic pain has become the main postoperative complication after surgical inguinal hernia repair, especially following Lichtenstein. Preliminary experiences with a soft mesh positioned in the preperitoneal space (PPS) by transinguinal preperitoneal (TIPP) or total extraperitoneal (TEP) technique, showed promising results considering the reduction of postoperative chronic pain. Evolution of surgical innovations for inguinal hernia repair led to an open, direct approach with preperitoneal mesh position, such as TIPP. Based on the TIPP procedure, another preperitoneal repair has been recently developed, the transrectus sheath preperitoneal (TREPP) mesh repair.
The ENTREPPMENT trial is a multicentre randomized clinical trial. Patients will be randomly allocated to anterior inguinal hernia repair according to the TREPP mesh repair or TIPP procedure. All patients with a primary unilateral inguinal hernia, eligible for operation, will be invited to participate in the trial. The primary outcome measure will be the number of patients with postoperative chronic pain. Secondary outcome measures will be serious adverse events (SAEs), including recurrence, hemorrhage, return to daily activities (for example work), operative time and hospital stay. Alongside the trial health status, an economic evaluation will be performed. To demonstrate that inguinal hernia repair according to the TREPP technique reduces the percentage of patients with postoperative chronic pain from 12% to <6%, a sample size of 800 patients is required (two-sided test, α = 0.05, 80% power).The ENTREPPMENT trial aims to evaluate the TREPP and TIPP procedures from patients’ perspective. It is hypothesized that the TREPP technique may reduce the number of patients with any form of postoperative chronic pain by 50% compared to the TIPP procedure.
Current Controlled Trials:
Chronic pain; Inguinal; Hernia; Preperitoneal; Mesh; TREPP; TIPP; Open repair; Trial; Randomized
Chronic pain is the main drawback of the Lichtenstein procedure for inguinal hernia repair, with a reported incidence of 15–40%. The transinguinal pre-peritoneal (TIPP) technique seems to be associated with less chronic pain, comparable to the total extra peritoneal (TEP) technique. The aim of this study was to evaluate 3 years of TIPP and Lichtenstein experience since the start of our Hernia Center Brabant in January 2006.
Patient records of unilateral primary inguinal anterior hernia corrections (TIPP and Lichtenstein) performed since the opening of Hernia Center Brabant (2006–2008) were evaluated in a retrospective study. ASA class 4 and 5, <18 years, recurrences and bilateral hernias were excluded. In the TIPP technique, a Polysoft™ Hernia Patch was placed into the preperitoneal space using an anterior protocol led approach. The Lichtenstein technique was performed as described by Amid [Amid et al (1996) Eur J Surg 162:447–453] and modified with a soft mesh. One of the hernia surgeons decided peroperatively which technique to perform. Baseline characteristics and postoperative complications were assessed retrospectively. The attempted follow up period was 6 months. Chronic pain was assessed in both groups as mild (VAS 1–3), moderate (VAS 4–6) or severe (VAS 7–10). Chronic pain was defined in both groups as any pain sensation lasting longer than 3 months postoperatively, or when local injection of analgesia was necessary. Patients who did not come back because of chronic pain after regular follow up were regarded as free of pain.
A total of 496 patients were included in this study; 225 TIPP and 271 Lichtenstein anterior inguinal hernia operations were analyzed. Data from one TIPP-patient were lost. Both groups were comparable with regard to baseline characteristics regarding age (p = 0.059), gender (p = 0.478) and ASA-classification (p = 0.104). TIPP: mean age 52.7 years, ASA-classification I: 54%, II: 36% and III: 5.3%. A total of 7.6% complications were assessed; recurrence (n = 1), bleeding (and re-operation) (n = 4); 10 patients (4.4%) experienced chronic pain. Persisting sensation loss occurred in 0.9%. Lichtenstein: mean age 57.3 years, ASA-classification I: 51%, II: 38% and III: 11%. A total of 8.5% complications were assessed; recurrence (n = 3), bleeding (and re-operation) (n = 3); 11 Lichtenstein patients (4.1%) experienced chronic pain. Persisting sensation loss occurred in 2.2%. Limitations of this retrospective study were incomplete follow up (31.3% had only one post operative visit 14 days after surgery) and these patients were further regarded as free of pain. Therefore, possible under-reporting of chronic pain could be present. The study was not double blind.
This retrospective study design revealed no significantly better results for the TIPP procedure as compared to the Lichtenstein technique. The incidence of chronic pain reported in this retrospective study has been low in both groups since the opening of the Hernia Center Brabant. These results form the basis for a prospective randomized clinical trial comparing the TIPP and Lichtenstein techniques: ISRCTN93798494.
TIPP; Inguinal hernia repair; Anterior; Lichtenstein; Surgery
Inguinal hernia repair is one of the most frequently performed procedures in Switzerland (15'000/year). The most common complication postoperatively is development of chronic pain in up to 30% of all patients irrespective of the operative technique.
264 patients scheduled for an inguinal hernia repair using one of three procedures (Lichtenstein, Barwell and TEP = total extraperitoneal hernioplasty) are being randomly allocated intra-operatively into two groups. Group I patients receive a local injection of 20 ml Carbostesin® 0.25% at the end of the operation according to a standardised procedure. Group II patients get a 20 ml placebo (0.9% Saline) injection. We use pre-filled identically looking syringes for blinded injection, i.e. the patient, the surgeon and the examinator who performs the postoperative clinical follow-ups remain unaware of group allocation. The primary outcome of the study is the occurrence of developing chronic pain (defined as persistent pain at 3 months FU) measured by VAS and Pain Matcher® device (Cefar Medical AB, Lund, Sweden).
The study started on July 2006. In addition to a sample size re-evaluation three interim analyses are planned after 120, 180 and 240 patients had finished their 3-months follow-up to allow for early study termination.
Using a group sequential study design the minimum number of patients are enrolled to reach a valid conclusion before the end of the study.
To limit subjectivity, both a VAS and the Pain Matcher® device are used for the evaluation of pain. This allows us also to compare these two methods and further assess the use of Pain Matcher® in clinical routine.
The occurrence of chronic pain after inguinal hernia repair has been in focus of several clinical studies but the reduction of it has been rarely investigated. We hope to significantly reduce the occurrence of this complication with our investigated intervention.
Our trial has been registered at ClinicalTrials.gov. The trial registration number is: [NCT00484731].
A 52-year-old man with left indirect groin hernia was admitted for elective inguinal repair using the totally extraperitoneal (TEP) approach. After an uneventful intubation, TEP repair of the hernia was performed with three midline trocars. Immediately after extubation, the patient noted severe chest pain. There was a decrease in PaO2 saturation, and neck subcutaneous emphysema was detected. There was no emphysema of the abdomen or of the back. A chest film and thoracic computed tomographic (CT) scan confirmed the presence of pneumomediastinum without pneumothorax. The patient was discharged without complications.
Totally extraperitoneal hernia repair; Laparoscopy; Pneumomediastinum
We experienced an extremely rare complication during performance of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair for a 57-year-old healthy man. About 50 minutes after CO2 insufflation, the patient developed tachycardia, hypoxemia, hypercapnia and an increased airway pressure. Right pneumothorax with subcutaneous emphysema was recognized on the emergency chest X-ray and this was successfully treated by chest tube insertion. Anesthesiologists should be aware of the possible occurrence of pneumothorax during laparoscopic TEP hernia repair.
Hernia repair; Laparoscopy; Pneumothorax; Subcutaneous emphysema
Laparoscopic herniorrhaphy is a well-debated approach to inguinal hernia repair. Multiple technical and outcome variables have been compared with those of traditional open inguinal hernia repairs. One of these variables is the choice of anesthesia. To date, no reports describe the use of spinal anesthesia for laparoscopic hernia repairs. We present herein a review of our experience with spinal anesthesia for the total extraperitoneal preperitoneal laparoscopic hernia repair (TEP).
We prospectively reviewed 30 patients undergoing TEP while under spinal anesthesia. Methods of anesthesia, surgical procedure, operative and anesthesia delivery times, as well as outcomes were reviewed. Patients were followed up over a 2-year period. Short- and long-term results of the surgical procedure and anesthesia delivered were noted.
All patients underwent successful laparoscopic hernia repair while under spinal anesthesia without conversion to general anesthesia. Forty-four hernias were repaired in 30 patients. Short- and long-term follow-up (2 years) revealed no significant untoward affects from the spinal anesthesia in this series of patients. Aside from inguinodynia in 3 patients in the short-term, no other short-term or long-term untoward sequelae occurred.
Spinal anesthesia is a feasible, and in our experience, the preferable method of anesthesia for total extraperitoneal laparoscopic hernia repair.
Laparoscopic hernia repair; Spinal anesthesia; Totally extraperitoneal preperitoneal hernia repair; Hernia; Inguinal surgery; Laparoscopy; Regional anesthesia
A case is presented of a male patient that presented with intestinal obstruction in the early postoperative period of a transabdominal preperitoneal inguinal repair (TAPP) that was diagnosed and repaired successfully using laparoscopy. Whenever a total extraperitoneal procedure (TEP) cannot be performed, the peritoneal closure of the TAPP should be done water-tight using interrupted stitches of absorbable monofilament sutures.
Laparoscopy; TAPP hernia repair; Bowel obstruction
Laparoscopic inguinal hernia repairs are looked upon as technically demanding procedures having have a stiff ‘learning curve’ associated with its performance in terms of clinical outcome and patient's satisfaction. Complication rates have been shown to drop with increased surgical experience. The complication rate for laparoscopic repair of inguinal hernia ranges from less than 3% to as high as 20%. Complications of a totally extraperitoneal (TEP) repair include general complications that occur with any surgical procedure and anesthesia, mesh-related complications and those specific to the TEP procedure, like visceral injury, vascular injury, nerve injury and injury to the cord. Intraoperative complications can occur at every step of the operation, even though some of them are only occasionally reported. However, it is important to analyze all of them chronologically, so that we can define methods to prevent them or tackle them if they occur. Risk reduction strategies are required to improve the clinical outcome of TEP and this must be adopted for each individual surgical step.
Complications; inguinal hernia; inguinal hernia repair; laparoscopic surgery; total extraperitoneal
A 53-year-old Caucasian male underwent laparoscopic total extraperitoneal repair of a right indirect inguinal hernia. Postoperatively, the patient developed right testicular swelling and pain that increased over the course of a week. On examination, the patient was found to have a tender, swollen, high-riding testicle, and testicular torsion was of main concern. Doppler sonography and testicular scan suggested an infarction only to the upper pole of the right testicle. Subsequent exploration of the right testicle revealed a hydrocele and focal ischemia to the upper pole of the right testicle. Intraoperative Doppler study and a urology consultation were obtained with an initial impression of possible intermittent torsion. This report describes a rare complication seen in laparoscopic inguinal hernia repairs.