|Year : 2021 | Volume
| Issue : 1 | Page : 19-24
Comparison of trans-abdominal preperitoneal repair with Lichtenstein tension-free hernioplasty: A prospective study
Tanweer Karim, Vivek Kumar Katiyar, Atul Jain, Gaurav Patel, Sajid Maqbul Nurbhai, Ram Bharosh Kumar
Department of Surgery, ESI PGIMSR, New Delhi, India
|Date of Submission||03-Jun-2020|
|Date of Decision||02-Jul-2020|
|Date of Acceptance||08-Sep-2020|
|Date of Web Publication||22-Jan-2021|
Department of Surgery, ESI PGIMSR, Basaidarapur, New Delhi
Source of Support: None, Conflict of Interest: None
Background: The concept of hernial repair underwent evolution from Bassini's repair to Lichtenstein tension-free repair with the introduction of polyethylene mesh. Recently, some of the prosthetic biomaterials have been combined to form composite mesh to minimize undesirable side effects. Mesh placement can be achieved by both open and laparoscopic techniques. Although many studies have explored the relative merits and potential risks of laparoscopic surgery for the repair of inguinal hernia, most individual trials have been too small to show clear benefits of one type of surgical repair over another.
Materials and Methods: A randomized comparative study, was conducted for duration of 18 months. Patients of Unilateral Uncomplicated Inguinal hernia between the age group of 18-60 years, was randomized between two groups. Patient were operated by Surgeons having requisite experience of TAPP repair and Lichtenstein repair.
Results: A total of 110 patients included in this study were male with unilateral uncomplicated inguinal hernia. The mean operative time for open Lichtenstein mesh repair and TAPP was 52.85 min and 64.27 min, respectively. The postoperative pain score (as per visual analog scoring) was statistically significantly less in laparoscopic TAPP group as compared to that of open Lichtenstein group (P < 0.05). No major complications were noted in either Lichtenstein group or TAPP group. The minor complication rate was 20.0% for open Lichtenstein group and 7.27% for laparoscopic TAPP group. The mean time to return to work was earlier for TAPP group (12.97 days) as compared to that of Lichtenstein group (17.84 days).
Conclusion: The results support the view that laparoscopic TAPP mesh repair is as safe and efficient as Lichtenstein inguinal hernia repair and should be an available option for all patients requiring elective hernioplasty.
Keywords: Inguinal hernia, inguinal hernioplasty, Lichtenstein repair, total extraperitoneal hernia repair, trans-abdominal preperitoneal repair
|How to cite this article:|
Karim T, Katiyar VK, Jain A, Patel G, Nurbhai SM, Kumar RB. Comparison of trans-abdominal preperitoneal repair with Lichtenstein tension-free hernioplasty: A prospective study. Formos J Surg 2021;54:19-24
|How to cite this URL:|
Karim T, Katiyar VK, Jain A, Patel G, Nurbhai SM, Kumar RB. Comparison of trans-abdominal preperitoneal repair with Lichtenstein tension-free hernioplasty: A prospective study. Formos J Surg [serial online] 2021 [cited 2021 Mar 6];54:19-24. Available from: https://www.e-fjs.org/text.asp?2021/54/1/19/307625
| Introduction|| |
Approximately 75% of all abdominal wall hernias occur in the groin. Inguinal hernias are more common on the right than on the left and are seven times more likely in males than in females. Indirect inguinal hernias are more common than direct hernias. Femoral hernias are much less common than either, accounting for fewer than 10% of all groin hernias.
The cause of an inguinal hernia is far from completely understood, but it is multifactorial. Groin hernias share the common feature of emerging through the myopectineal orifice of Fruchaud. It serves as the passage for blood vessels, nerves, lymphatic, muscles, and tendons between the abdomen and the lower limb.
General factors such as weakening of muscle and fascia by advancing age; lack of physical exercise; obesity and urological and appendectomy incision; pulmonary diseases such as chronic obstructive pulmonary disease and emphysema; chronic constipation; genito-urinary causes such as prostatomegaly; cystitis; cystocele; and urethrocele contribute to the formation of groin hernia. Other factors include failure of shutter mechanism; smoking and congenital connective tissue disorders such as Marfan's, Ehlers–Danlos, Hurler–Hunter syndromes; and mesenchymal metabolic defects, causing a deficiency and structural abnormalities of the collagen fibers, predisposing to groin hernia.
Inguinal hernial repair is one of the most frequently performed operations in general surgery. The standard method for inguinal hernial repair had changed little over a hundred years until the introduction of synthetic mesh. This mesh can be placed by either using an open approach or by using a minimal access laparoscopic technique. The concept of hernial repair underwent evolution from Bassini's repair to Lichtenstein tension-free repair with the introduction of polyethylene mesh. Recently, some of the prosthetic biomaterials have been combined to form composite mesh in order to minimize undesirable side effects. Mesh placement can be achieved by both open and laparoscopic techniques.
Trans-abdominal preperitoneal (TAPP) repair involves access to the hernia through the peritoneal cavity. Mesh is placed in the preperitoneal space, after incising and dissecting parietal peritoneum, over all the potential hernial sites in the inguinal region. The peritoneum is then closed above the mesh.
Total extraperitoneal (TEP) repair is the newer laparoscopic technique, in which the hernial site is accessed via the preperitoneal plane without entering the peritoneal cavity. TEP repair is technically more demanding than the TAPP technique, as the operating space is more constrained in comparison to TAPP and requires more expertise in laparoscopic hernial surgery. The TAPP approach is usually adopted by the surgeons at the beginning, and TEP is adopted as the learning curve grows. The TEP reduces the chances of intraperitoneal injury, but conversion to TAPP/open repair is also reported. In multicentric study, it was found that in intraoperative and postoperative complications, there was no significant difference between TAPP and TEP.
The potential benefits of using a laparoscopic approach include reduced postoperative pain, earlier return to normal activities, and a reduction in long-term pain and numbness. The repair of bilateral hernias (including occult hernias detected during contralateral inspection at the time of a unilateral repair) may be undertaken during the same operation. However, laparoscopic surgery is associated with additional costs, for the endoscopy system (video unit, monitor, endoscope, and CO2 insufflator) and instruments (staplers, diathermy scissors, or ports), although these may be reusable. Today, inguinal hernial repair is one of the most commonly performed general surgical procedures in the USA, accounting for 10%–15% of all operations.
Aims and objectives
The objectives of the study were to compare the following parameters between the two commonly performed methods of hernia repair, namely the open Lichtenstein hernioplasty and TAPP hernioplasty repair of inguinal hernia:
- Postoperative pain
- Surgical complications of each procedure
- Duration of surgery
- Duration required to get back to normal activities
- Early recurrence rates.
| Materials and Methods|| |
The present study, a randomized comparative study, was conducted in the department of surgery, for a duration of 18 months. After the approval of the ethical committee approval letter number: DM (A) H-19/14/17/IEC/2012-PGIMSR, patients with unilateral uncomplicated inguinal hernia, between the age group of 18 and 60 years, were randomized between two groups (sealed envelope system). Elective surgery was enrolled for the study, and informed consent was obtained from all patients after randomization. Patients were operated by surgeons having requisite experience of TAPP repair and Lichtenstein repair.
The primary end points were as follows:
- Early postoperative pain assessed by visual analog scale (VAS)
- Proportion of patients with substantial pain resulting in impairment of function at 6-month follow-up.
The secondary end points were as follows:
- Incision to suture time in minutes
- Proportion of patients with operative complications
- Duration of stay and time to return to daily activities
We chose a 40% baseline ratio of complete response (no/mild pain) in Lichtenstein hernioplasty from the previous experience. For the sample size calculation, we defined a relevant difference of 30% in the complete response between the two groups in uncomplicated unilateral inguinal hernia. Using a one-tailed alpha value (0.05) and a beta value (0.2), 45 patients per group would be sufficient to detect a significant difference. However, considering attrition of case under the study, we would like to include 55 patients per group.
The formula for calculated sample size is given below:
(P1 − P2)2 where
P1 = Anticipated proportion of response rate in Lichtenstein hernioplasty
P2 = Anticipated proportion of response rate in TAPP: P = (P1 + P2)/2
All adult patients with unilateral uncomplicated inguinal hernia fulfilling the inclusion and exclusion criteria constituted the study population.
- Unilateral uncomplicated hernia
- Age 18–60 years
- American Society of Anesthesiologists (ASA) grading I and II
- Willing to participate in the study.
- Not willing for consent
- ASA III and ASA IV
- Complicated hernia (massive scrotal hernia with hydrocele and sliding hernia)
- Previous major pelvic surgery
- Uncontrolled bleeding diathesis
- Impaired cognitive function.
Statistical testing was conducted with the Statistical Package for the Social Sciences version 17.0 - by IBM SPSS Statistics for windows for use in India. Continuous variables were presented as mean ± standard deviation or median if the data were unevenly distributed. Categorical variables were expressed as frequencies and percentages. The comparison of normally distributed continuous variables between the groups was performed using Student's t-test (unpaired t-test). Nominal categorical data between the groups were compared. For all statistical tests, P < 0.05 was taken to indicate a significant difference.
| Results|| |
The mean age of patients undergoing Lichtenstein repair was 45.44 years and TAPP repair was 41.60 years. This difference was considered statistically insignificant (P = 0.072). All patients were male, of which 19 (17.27%) patients belonged to 18–30 years' age group, 18 (16.36%) patients to 31–40 years' age group, 41 (37.27%) patients to 41–50 years' age group, and 32 (29.09%) patients were aged between 51 and 60 years. The data are tabulated in [Table 1].
In our study, 67 (60.90%) patients had right-sided inguinal hernia and 43 (39.09%) had left-sided inguinal hernia. Fifty-four (49.09%) cases had direct and 56 (50.90%) had indirect inguinal hernia. Indirect inguinal hernia was more common in younger age group than direct hernia which was more common in older age group.
The patients were scored on a VAS of 1–10 for assessing the postoperative pain. Pain was assessed on predetermined intervals of 6, 24, and 48 h, day 8, day 30, day 90, and day 180. The pain score was statistically significantly less (P < 0.05) in the TAPP repair group (4.07) as compared to the pain score in the Lichtenstein group (4.78) after 6 h of surgery, but in the individual age group, there was no significant difference in different age groups except the age group of 41–50 years [Table 2]. The pain score was statistically significantly less (P < 0.05) in the TAPP repair group (2.69) as compared to the Lichtenstein group repair group (3.09), after 24 h of surgery, but in individual age group, there was no significant difference in different age groups [Table 3]. In our study, even after 48 h, the pain score significantly reduced from day 0 and the pain score was statistically significantly less (P < 0.05) in the TAPP repair group (1.71) as compared to the pain score in the Lichtenstein group (2.44) after 48 h of surgery, but in individual age group, there was no significant difference in different age groups [Table 4]. Chronic inguinal pain in open Lichtenstein group on day 90 as well as day 180 was in six patients and two patients as compared with TAPP group which was in four patients on day 90 and three patients on day 180. The difference of chronic pain between the two groups was statistically insignificant.
Operative time was calculated from the time of incision made to the time of wound closure. In our study, the overall mean operative time in the Lichtenstein group was 52.82 min, which was statistically significantly less (P < 0.05) than that of the laparoscopic TAPP group, which was 64.27 and in individual age group, there was significant difference in different age groups [Table 5].
Patients after TAPP repair could resume their work significantly (P < 0.05) earlier (mean 12.49 days) as compared to patients following Lichtenstein repair (mean 17.84 days). Return to work was earlier in younger age group as compared to older age group. There were 15 (13.63%) patients who had minor complications, as listed in [Table 6]. Minor complications were seen in 11 (20.0%) patients of the Lichtenstein group and 4 (7.27%) patients of TAPP repair. These were seroma and hematoma formation, testicular swelling, and local wound infection. There were two incidences of early recurrences in the Lichtenstein group and one in TAPP repair within 6 months of primary repair. The difference of recurrence was statistically insignificant.
|Table 6: Return to work in days among patients of the study groups (mean)|
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| Discussion|| |
Although many studies have explored the relative merits and potential risks of laparoscopic surgery for the repair of inguinal hernia, most individual trials have been too small to show clear benefits of one type of surgical repair over another. However, it is still important to consider the factors that impact the efficiency of each procedure including the operative time, the technical difficulty, the experience required, the procedure cost, and the reimbursement associated with each procedure. These factors can determine the feasibility of each procedure considering the available resources at an institution.
In our study, the mean operative time was 52.82 min for Lichtenstein hernia repair and for 64.27 min for laparoscopic. Hence, the overall mean operative time was significantly less in open hernia repair than that in laparoscopic repair, which is comparable to other studies.
About operative time, most studies in the literature points to a lesser operation duration with open repair., The 2003 Cochrane database systematic review demonstrated that the duration of operation was longer in the laparoscopic group (mean difference 14.81 min; P < 0.0001). A meta-analysis in the British Journal of Surgery described a similar increase of 15.2 min with laparoscopic inguinal hernia repair (P < 0.001).
According to Jain and Norbu's study, laparoscopic groin hernia repair takes longer time than open mesh repair. A meta-analysis of 16 randomized trials of TAPP repair demonstrated an overall increase of minutes compared with open repair. Memon et al. reviewed the data from 29 randomized clinical trials and concluded that patients who underwent laparoscopic repair of groin hernia had longer duration of surgery.
Postoperative pain is an important outcome to consider between laparoscopic and open repair of inguinal hernias. A meta-analysis published in the British Journal of Surgery in 2010 used chronic pain as a primary outcome and found no significant difference between the laparoscopic and open cohorts. However, these results differ from many other reports including the 2003 Cochrane database systematic review, which reported less persisting pain (overall 290/2101 vs. 459/2399, P < 0.0001) in the laparoscopic groups. In our study, the pain score (as per visual analog scoring) was significantly less in TAPP repair group as compared to Lichtenstein repair group with P < 0.05 after 6 h, 24 h, and 48 h.
Another variable that is used as an outcome in our study comparing laparoscopic and open technique is return to work. There is a consensus in that patients who undergo laparoscopic inguinal hernia repair have a shorter convalescence and earlier return to work and activities, compared with those who underwent open mesh, inguinal hernial repair.,, The time taken to resume work in 18–30 years' age group in TAPP group patients was 8.8 days compared to 13.8 days in the open group. In 31–40 years' age group 11.2 days was taken in the TAPP group and 18 days in the open group. The mean time to resume work was 12.4 days in TAPP patients in comparison to 17.8 days for open group patients. Being able to resume work earlier is beneficial to the patient both physically and mentally with the economic advantage to the patient and government.
Recurrence is arguably the most important indicator of the success of a hernial procedure. Hernial recurrences after surgical repair may occur in 15% of the cases or more. The frequency of hernial recurrence depends on several factors including the type of hernial repair initially performed, the comorbidities of the patient, and the length of time from the original hernia repair. A meta-analysis published in the British Journal of Surgery in 2000 reported similar finding in that overall recurrences did not differ between the laparoscopic and open groups.
In our study, it was evident that the postoperative and chronic inguinal pain, time to resume work, postoperative complications and recurrence were less in TAPP as compared to open surgery as seen in other studies, and it serves as an advantageous aid to the young and working population and scars are cosmetically more acceptable.
| Conclusion|| |
The results support the view that laparoscopic TAPP mesh repair is as safe and efficient as Lichtenstein inguinal hernial repair and should be an available option for all patients requiring elective hernioplasty. The postoperative pain and time to return to work are significantly lesser in patients who undergo laparoscopic TAPP repair and it is an advantage over Lichtenstein hernia repair. However, operation time is significantly longer in TAPP repair as compared to Lichtenstein repair, and there appears insignificant difference among the complication rate and recurrence. Although the study supports the view that TAPP mesh repair is a safe procedure with lesser postoperative pain and recurrence, studies on larger sample size with longer postoperative follow-up will be required to establish it further.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]