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ORIGINAL ARTICLE
Year : 2020  |  Volume : 39  |  Issue : 2  |  Page : 461-465

Laparoscopic totally extraperitoneal hernioplasty: Theodor Bilharz Research Institute preliminary experience


Department of General Surgery, Theodor Bilharz Research Institute, Giza, Egypt

Date of Submission02-Jan-2020
Date of Acceptance19-Jan-2020
Date of Web Publication27-Apr-2020

Correspondence Address:
MD Hesham A Elmeligy

Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejs.ejs_2_20

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  Abstract 


Background The two standard methods for inguinal hernioplasty is open and minimal access laparoscopic technique. Most laparoscopic surgeons use a transabdominal preperitoneal approach but totally extraperitoneal (TEP) approach potentially offers several advantages.
Objective The aim in this study was to assess the learning curve, cost value, safety, and feasibility of TEP approach.
Patients and methods Prospectively collected data on 185 consecutive patients submitted to laparoscopic TEP hernioplasty for inguinal hernia from 2016 to 2018 in Theodor Bilharz Research Institute Hospital. This study involved repair of primary, recurrent inguinal hernia and femoral hernia. The prolene mesh was used for groin hernia repair in all cases with and without fixation.
Results All 185 cases started with the laparoscopic TEP technique with only four cases converted to transabdominal preperitoneal technique (2.1%). In 110 (60.7%) cases the mesh was placed without fixation. In 71 cases the mesh was fixed by Tackers or Histoacryl. In unilateral hernia, the mean operating time was 45 min, while in bilateral hernia it was 61 min. Intraoperative complications included three cases of inferior epigastric vessel injury which were managed by metallic clips of 5 mm. The mean pain score was 7.5, while the mean satisfaction score was 5.4. The mean hospital stay was 16.4 h. Regarding postoperative complications, 10 (5.5%) patients developed a postoperative seroma, four (2.1%) patients developed a hematoma, two (1.1%) patients developed a hydrocele, and five (2.7%) patients experienced neuropathic pain. There were three (1.1%) recurrent cases; all these cases were managed by open hernioplasty.
Conclusion In this study, the laparoscopic TEP approach is found to be an effective, and safe technique regarding primary, recurrent open inguinal and femoral hernias with good learning curve to laparoscopic surgeon who started with transabdominal preperitoneal technique technique.

Keywords: inguinal hernia, laparoscopic hernioplasty, total extraperitoneal approach


How to cite this article:
Elmeligy HA, Nafea AE, Esmat ME, Abdelaziz AM, Mostafa A. Laparoscopic totally extraperitoneal hernioplasty: Theodor Bilharz Research Institute preliminary experience. Egypt J Surg 2020;39:461-5

How to cite this URL:
Elmeligy HA, Nafea AE, Esmat ME, Abdelaziz AM, Mostafa A. Laparoscopic totally extraperitoneal hernioplasty: Theodor Bilharz Research Institute preliminary experience. Egypt J Surg [serial online] 2020 [cited 2020 Sep 28];39:461-5. Available from: http://www.ejs.eg.net/text.asp?2020/39/2/461/283183




  Introduction Top


The most frequently performed operation in general surgery is inguinal hernia repair. Over a hundred years the standard method for inguinal hernia repair had minor changes until the introduction of synthetic mesh which can be placed by the open approach or by using a minimally access laparoscopic technique [1].

Laparoscopic hernioplasty evolved from the Stoppa operation with placing a prosthetic mesh in the preperitoneal space over the myopectineal orifice for the reinforcement of fascia transversalis. In the early 1990s, Arregui and Doin introduced the transabdominal preperitoneal technique (TAPP). With TAPP approach we can identify a missed additional direct or femoral hernia during the operation. Then Phillips and McKernan described the totally extraperitoneal (TEP) approach of endoscopic hernioplasty without breaching the peritoneal cavity [2].

Recommendations of The Royal College of Surgeons of England for the laparoscopic approach are: bilateral hernias, groin hernia in women, recurrent hernias after open hernioplasty, and hernias in young men who are active or who complain of predominant groin pain [3].

Initially, most laparoscopic surgeons used a TAPP technique to reach the preperitoneal space of the groin. This technique was more familiar and much easier than the one that required exposing the extraperitoneal space without breaching the peritoneal cavity laparoscopically. A totally extraperitoneal technique potentially offers several advantages. It might eliminate complications related to entering the peritoneal cavity to reach the extraperitoneal space and might reduce operative time especially for bilateral hernia repairs [4].


  Patients and methods Top


A prospectively collected data on 185 patients submitted to laparoscopic TEP hernioplasty for inguinal hernia from 2016 to 2018 in Theodor Bilharz Research Institute Hospital. Inclusion and exclusion criteria are shown in [Table 1].
Table 1 Inclusion and exclusion criteria

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All patients were subjected to history taking, general examination, and routine preoperative assessment including abdominal ultrasonography, informed written consent approved by the Ethics Committee of TBRI, evaluations of the operative time, and any intraoperative complications, postoperative pain score, need for analgesia, hospital stay, and postoperative complications.

All operations were performed by surgeons who have specialized in laparoscopic surgery. Prophylactic antibiotic was given on induction for all patients. Under general anesthesia, the patients were placed in supine position adducting the two arms, and a Foley catheter was inserted intraoperatively, which was removed immediately after operation.

Operative techniques

Scrubbing of the abdomen starts from the nipple to the knees. The surgeon and the assistance stand on the either side of the hernia beside the patient head while the screen and the laparoscopic set were placed on the side of the hernia beside the patient foot. Insufflation of extraperitoneal space was accomplished through an infraumbilical incision to the anterior rectus sheath on the same side of the hernia by the insertion of a 10 mm laparoscopic trocar into the preperitoneal cavity between the rectus muscle and the posterior rectus sheath. A 10 mm scope (0°) was used to bluntly dissect the preperitoneal space till the superior pubic remus is seen and then a 30° scope was used. Two other 5 mm working ports were inserted in the midline: one at the pubic tubercle and the other mid-way between the two ports. After dissection of the sac from the cord with the identification of the triangle of dome and pain ([Figure 1]), we placed a 12×15 cm prolene mesh for inguinal repair in all cases. It was inserted through a 10 mm port and then it was laid in the preperitoneal space over the inguinal area with fixation by Tackers or Histoacryl (Covidin, USA) (2 cm was injected percutaneous by drop technique at the pubic tubercle and the triangle of pain) and others without fixation (The mesh was marked by two small metallic clips 5 mm at the pubic tubercle edge and the other at the anterior superior iliac spine edge which was checked by plain radiograph on erect position after 1 week) ([Figure 2],[Figure 3],[Figure 4],[Figure 5]) followed by the release of the pneumoperitoneal gas. Then closing the anterior rectal sheath of 10 mm port by prolene 2/0 followed by skin closure.
Figure 1 After dissection of the sac.

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Figure 2 The prolene mesh used in our study.

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Figure 3 Marking of the anterior superior iliac spine edge with single clip.

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Figure 4 Mesh placement.

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Figure 5 Postoperative plain radiography (Erect position).

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Postoperative pain score for the first week was determined by asking each patient to express the level of postoperative pain in the range of 0 (no pain) to 10 (most pain). The score of hospital stay and patient’s satisfaction was determined by a seven-point Likert-like verbal rating scale, starting with 1=extremely dissatisfied, 2=dissatisfied, 3=somewhat dissatisfied, 4=undecided, 5=somewhat satisfied, 6=satisfied, and ending by 7=extremely satisfied.

The aim of our study was to assess the learning curve, safety, and feasibility of TEP approach regarding intraoperative and postoperative parameters ([Table 2]).
Table 2 Intraoperative and postoperative parameters

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Results were collected, tabulated, and evaluated based mainly on the learning curve, cost value, safety, and feasibility of TEP approach.

Statistical analysis

Our statistical analysis was determined by the nonparametric test using the T test for groups’ comparisons and accepting a significance level at P=0.05 while presenting our data as median range.

Approval of the study

Approval of the study by our local Ethics Committee in Theodor Bilhariz Research Institute and conducted as per the Helsinki II Declaration. An IRB form and written consent form were obtained from all patients after detailed explanation of the procedures and its possible complications.


  Results Top


In all, 185 consecutive patients submitted to laparoscopic TEP hernioplasty for inguinal hernia from 2016 to 2018 in Theodor Bilhariz Research Institute Hospital. There were 173 men and 12 women with a median age of 36 years (range: 16–60 years): 185 hernias (20 bilateral, 165 unilateral), 181 cases of inguinal hernioplasty (42 direct, 139 indirect), and four femoral hernias were done. Eight (4%) patients underwent recurrent hernia repairs ([Table 3]).
Table 3 Patients’ preoperative data

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All cases (185) were subjected to laparoscopic TEP technique with four cases converted to TAPP (2.1%) due to breaching of the peritoneum with no need to convert it to open surgery. In 110 (60.7%) cases, the mesh was placed without fixation. In 71 cases, the mesh was fixed [51 (28.2%) cases by Tackers and 20 (11.1%) cases by Histoacryl]. Our mean operating time for unilateral hernioplasty was 45 min (30–75 min), while in the bilateral one it was 61 min (53–95 min). Intraoperative complications included three cases of inferior epigastric vessel injury which where managed by metallic clips of 5 mm ([Table 4]). There was improvement in operative times and length of hospital stay with increasing numbers of cases. The learning curve for the laparoscopic surgeon who started with the TAPP technique shows a great difference to those started with the TEP technique presented by decreasing the operative time in those started by TAPP technique than in those started by the TEPP technique.
Table 4 Patients’ operative data

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The mean pain score was 7.5 while the mean satisfaction score was 5.4. With regard to hospital stay, the average was 16.4 h (6–24 h). With a median follow-up time of 12 months (6–18 months) from the data collected (n=181), 10 (5.5%) patients developed a postoperative seroma, four (2.1%) patients developed a hematoma, two (1.1%) patients developed a hydrocele, and five (2.7%) patients experienced neuropathic pain, all of which required no surgical interventions. There were three (1.1%) recurrent cases, two of them were in the cases without fixation, and one case was fixed by Histoacryl. All these cases were managed by open hernioplasty ([Table 5]).
Table 5 Patients’ postoperative data

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  Discussion Top


In the last two decades, laparoscopic hernia repair has proven advantages over open surgical technique in early discharge from hospital and early return to work [5],[6].

From 37 studies, The National Institute for Health and Clinical Excellence carefully assess all the evidence for the laparoscopic technique in inguinal hernia surgery with proven earlier return to work and decreased postoperative pain but with more operating time required (average 13.3 min longer) [7].

Still the optimal technique for inguinal hernia repair is being debated. But with an experienced laparoscopic surgeon, the laparoscopic TEP hernia repair is documented as an ideal choice for inguinal hernioplasty in numerous studies [8],[9],[10].

Many surgeons still have not adopted this technique because of the long learning curve although most surgeons now agree that the laparoscopic approach is a viable option for inguinal hernioplasty, especially for bilateral and recurrent hernias. Laparoscopic hernioplasty is more difficult to learn than most other advanced laparoscopic procedures because of a complex anatomy in an unfamiliar space [11].

We present our preliminary experience of laparoscopic TEP hernioplasty in TBRI for the repair of inguinal hernias using a prosthetic mesh. Most of our patients in our study were men, and most of our repairs were unilateral indirect inguinal. There was improvement in operative times and length of hospital stay with increasing numbers of cases. The learning curve for the laparoscopic surgeon who started with the TAPP technique shows great difference to those started with TEP technique. Early postoperative complications were infrequent and over 6 months follow-up only three cases have recurrent hernias. The surgery was satisfactory for all cases.Over the past few years, several mesh fixation techniques have been proposed for laparoscopic inguinal hernioplasty, starting from biological and nonbiological glues, to permanent and absorbable tacks, to without fixation. The use of a self-gripping mesh in the open inguinal hernia repair over the short term improves pain and recurrence outcome [12].

In our study, we have 110 cases with mesh fixation, 51 with tackers fixations, and 20 with Histoacryl injection.


  Conclusion Top


In our study, laparoscopic TEP approach is an effective and safe technique regarding primary, recurrent open inguinal and femoral hernias with good learning curve to laparoscopic surgeon who started with TAPP technique. We need a more larger scale to master this approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hamza Y, Gabr E, Hammadi H, Khalil R. Four-arm randomized trial comparing laparoscopic and open hernia repairs. Int J Surg 2010; 8:25–28.  Back to cited text no. 1
    
2.
McCormack K, Scott NW, Go PM, Ross S. EU Hernia Trialists collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003; 1:CD001785.  Back to cited text no. 2
    
3.
Commissioning Guide, Groin Hernia. London: Royal College of Surgeons of England; 2013.  Back to cited text no. 3
    
4.
Nixon SJ, Kumar S. The totally extraperitoneal approach (TEP) to inguinal hernia repair. Surgeon 2005; 3:281–287.  Back to cited text no. 4
    
5.
Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc 1992; 2:53–58.  Back to cited text no. 5
    
6.
Dulucq JL. Treatment of inguinal hernia by insertion of a subperitoneal patch under pre-peritoneoscopy. Chirurgie 1992; 118:83–85.  Back to cited text no. 6
    
7.
(2004) NICE TA083 guidance DOH.  Back to cited text no. 7
    
8.
DeTurris SV, Cacchione RN, Mungara A, Pecoraro A, Ferzli GS. Laparoscopic herniorrhaphy: beyond the learning curve. J Am Coll Surg 2002; 194:65–73.  Back to cited text no. 8
    
9.
Lepere M, Benchetrit S, Debaert M, Detruit B, Dufilho A, Gaujoux D et al. A multicentric comparison of transabdominal versus totally extraperitoneal laparoscopic hernia repair using Parietex meshes. JSLS 2000; 4:147–153.  Back to cited text no. 9
    
10.
Ramshaw B, Shuler FW, Jones HB. Laparoscopic inguinal hernia repair: lessons learned after 1224 consecutive cases. Surg Endosc 2001; 15:50–54.  Back to cited text no. 10
    
11.
Ramshaw B, Abiad F, Voeller G, Wilson R, Mason E. Polyester (Parietex) mesh for total extraperitoneal laparoscopic inguinal hernia repair: Initial experience in the United States. Surg Endosc 2003; 17:498–501.  Back to cited text no. 11
    
12.
Pierides G, Schenin T, Remes V, Hermunen K, Vironen J. Randomized comparison of self-fixating and sutured mesh in open inguinal hernia repair. Br J Surg 2012; 99:630–636.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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