totally extraperitoneal inguinal hernia repair
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Laparoscopic inguinal herniorrhaphy gained recognition as a viable alternative to the open approach in the early 1990s.1It was based upon the principles of pre-peritoneal hernior-rhaphy with a mesh being used to cover the myopectineal orifice following reduction of the hernial sac.
Two laparoscopic techniques were popularised:the transabdominal pre-peritoneal (TAPP)and the totally extraperitoneal (TEP).Debate still remains over which technique is the superior.The popularity of TEP is growing,as many surgeons have become wary of the potential for complications when entering the peritoneal cavity using the transabdominal approach.TEP has demonstrated favourable short-term results,with regards to reduced post-operative stay,pain and earlier return to physical activity in comparison with open mesh repairs.2Studies have also demonstrated low rates of recurrence,particularly in the first few years following surgery,3,4but most have failed to achieve a dedicated long-term follow-up in a series of suffi-cient magnitude.In a large multicentred trial,a recurrence rate of 4.9%at 4years following TEP repair was reported.5A recurrence rate of 2%at 5years has been reported in the TEP arm of a randomised controlled trial comparing TEP with open repair,6whilst a smaller case series reported a rate of 1%.7However,both studies involved relatively few patients.
There is little data regarding the incidence of chronic pain by means of long-term follow-up after TEP repair.A multicentre trial assessing pain by postal follow-up,in
GENERAL SURGERY
Ann R Coll Surg Engl 2010;92:201–205doi 10.1308/003588410X12628812458455
The Royal College of Surgeons of England
KEYWORDS
Inguinal hernia –Laparoscopic surgery –Follow-up studies
CORRESPONDENCE TO
Mark Vipond,Department of General Surgery,Gloucestershire Royal Hospital,Great Western Road,Gloucester GL13NN,UK T:+44(0)8454226675;E:mark.vipond@https://www.sodocs.net/doc/f43848791.html,
Five-year prospective follow-up of 430laparoscopic totally extraperitoneal inguinal hernia repairs in 275patients
DE MESSENGER,S AROORI,MN VIPOND
Department of General Surgery,Gloucestershire Royal Hospital,Gloucester,UK
ABSTRACT
INTRODUCTION 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 275consecutive patients undergoing TEP repair between 1996and 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 6weeks and then annually for 5years following surgery.
RESULTS A total of 430repairs were performed in the 275patients (median age,56years;range,20–94years;men,97.5%).Bilateral repair was performed in 168patients (61.1%)and recurrent hernia repair in 79patients (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 5years was 1.1%per patient (three repairs).Recurrences were noted at 7months,2years and 4years following surgery.Chronic groin pain was reported by 21patients (7.6%),seven of whom required referral to the pain team.
CONCLUSIONS TEP hernia repair is associated with a recurrence rate of 1%at 5years in this series.Chronic groin symptoms are also acceptably few.This recurrence rate following TEP repair compares extremely favourably with open mesh repair,par-ticularly as it includes a high proportion of recurrent repairs.As well as the proven early benefits,TEP repair can be consid-ered a safe and durable procedure with excellent long-term results.
which the predominant operation was TEP,pain was reported in18.1%at5years.8The studies with5-year fol-low-up from TEP,reported overall incidences of chronic pain of9.4%6and14%,7respectively.
This prospective study focuses upon the5-year follow-up of a large case series undergoing TEP repair by a single sur-geon,with recurrence and incidence of chronic pain being taken as primary outcome measures.
Patients and Methods
This was a prospective study of275consecutive patients who underwent430TEP repairs between January1996and December2002.Patients with primary bilateral inguinal hernia,recurrent inguinal hernia and those with suspected Gilmore’s groin,were included within this cohort.Surgery for suspected Gilmore’s groin was reserved for those with a typical set of features and a failed trial of conservative man-agement.Mesh repair was undertaken on the affected side, irrespective of the presence of a hernia.Patient demograph-
ics,details of surgery,postoperative complications,recur-rence and chronic pain were collected from a prospective database and patient records.
Chronic pain was defined as pain persisting beyond3 months9and classified as being either mild,moderate or severe on a3-point verbal scale.All patients were reviewed in the out-patient clinic at6weeks following surgery and then annually for5years.Patients who failed to attend their 5-year appointment were contacted by telephone.
Surgery was performed under general anaesthesia using a standard operative technique.The senior author was present as either lead surgeon or first assistant in all cases. The pre-peritoneal space was entered lateral to the umbili-cus and was enlarged by the use of an extraview and then structural balloon(Covidien UK Commercial Limited). Pressure was maintained at12–14mmHg by continuous insufflation of carbon dioxide.A5-mm port was inserted in the midline below the umbilicus and another5-mm port adjacent to the anterior superior iliac spine(ASIS)on the side undergoing repair.A further port was placed adjacent to the ASIS on the contralateral side if a bilateral repair was undertaken.After reduction of the hernial sac,a15×10cm polyprolene mesh was used to cover the myopectineal ori-fice and fixed in place by titanium tacks(Pro Tac,Covidien, UK).An L-shaped slit in the inferior border of the mesh was passed from lateral to medial beneath the spermatic cord and fixed to the pectineal ligament.Further tacks were placed anteriorly on the under surface of rectus abdominus and the fascia transversalis laterally.Patients who required conversion to an open procedure underwent a pre-peri-toneal repair as described by Stoppa and Warlmount.10 The senior author’s technique of TEP repair was devel-oped following initial experience with laparoscopic extraperitoneal dissection in the early1990s.Prior to the first repair being undertaken in this series,the senior author had already performed40cases in the preceding2years.
Results
A total of430pre-peritoneal repairs were performed in275 patients(Table1).The median age was56years(range, 20–94years)and268(97.5%)patients were men.Bilateral hernia repair was performed in168patients(61.1%)and recurrent hernia repair in79patients(28.7%).
Ten patients(3.6%)underwent repair for suspected Gilmore’s groin,of which only one patient required repair of a hernia that was detectable at operation.The remaining nine repairs performed in the absence of a hernia were excluded from the analysis of recurrence.Two of these patients continued to experience pain,with one patient requiring referral to the pain team for nerve blockade.Both were included within the analysis of chronic pain.
Surgery was undertaken either by a specialist registrar or an equivalent grade trainee in34patients(12.4%)under direct supervision of the senior author.Two patients(0.7%) required conversion to an open pre-peritoneal repair. Incidental hernias were detected in27patients(9.8%)and repaired simultaneously.Of these,14were femoral,seven contralateral direct,three Spigelian,two contralateral recurrent and one contralateral indirect(Table2).The in-hospital mortality rate was zero and no patient experienced any major complications.Early complications were report-ed in53(19.3%)patients(Table3).These were15wound infections,10urinary retentions,eight seromas and seven haematomas(none of which required evacuation).Early postoperative pain(less than6weeks after surgery)was
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reported in five patients,all of whom had experienced pain pre-operatively.Two patients reported sensory disturbance in the distribution of the lateral femoral cutaneous nerve,suggestive of meralgia parasthetica,but did not require any specific treatment.
Five-year follow-up was achieved in 198(72%)patients,of whom 146(73.7%)attended their final clinic appointment and 52(26.3%)were contacted by telephone.Eleven (4%)patients died during their follow up-period from unrelated causes.There were three recurrent hernias identified,giv-
ing a recurrence rate at 5years of 1.5%per patient for all patients seen or questioned at 5years.Review of the notes of the patients who did not complete 5-year follow-up iden-tified no additional recurrences,giving an overall recur-rence rate for the cohort of 1.1%per patient (Table 4).Recurrences were noted at 7months,2years and 4years following surgery.
Chronic inguinal pain was reported by 21patients (7.6%),of whom 16had experienced pain prior to surgery.Seven patients required referral to the pain team,five of whom received ilio-inguinal and genitofemoral nerve blocks with Triamcinolone 40mg and Bupivacaine 0.5%20ml.Only two patients reported severe pain that restrict-ed daily physical activity with genitofemoral nerve entrap-ment being implicated in both https://www.sodocs.net/doc/f43848791.html,plete symp-tom resolution was achieved with nerve blocks and the application of topical capsaicin.Amongst the 14patients who were not referred to the pain team,symptoms had either resolved without treatment or were well controlled with simple analgesia.
Discussion
The long-term outcome following TEP hernia repair in this series compares extremely favourably with the results achieved from other studies looking at both laparoscopic and open methods of repair.5,7,10–14A recurrence rate of1.1%at5 years is one of the lowest reported for TEP repair in the litera-ture to date.This is particularly significant as almost one-third of patients underwent repair of a recurrent hernia.
The success of any hernia repair is determined by the recurrence rate and the incidence of chronic pain.Most recurrences after laparoscopic repair occur within the first year and are attributable to technical error.7,15Only one recurrence within a year was noted in the study and this occurred in a patient having repair of a recurrent direct hernia.An indirect recurrence was noted at subsequent repair.The recurrences amongst the primary repairs were seen at2years and4years following surgery.One patient had undergone repair of a direct hernia and the other an indirect hernia.Both recurrences were noted to be direct. Previous reports have suggested that recurrences have occurred after repair of direct hernias because of mesh migration16or using an inadequately sized mesh to allow for shrinkage.17There is much debate surrounding the need for mesh fixation in TEP repair,although the method employed in this series would suggest that fixation provides an effec-tive means of repair.
The incidence of chronic groin pain was acceptably low and comparable to previously reported figures following laparoscopic repair.5,7,8,10,12,13The majority of patients who developed chronic pain had experienced pain prior to sur-gery.Previous studies have demonstrated pre-operative inguinal pain to be a risk factor in developing chronic pain,5 highlighting the complex aetiology of this condition.In all but two patients,symptoms were rated as mild or moderate in nature.The results from this series lends support to a growing body of evidence that the laparoscopic approach, either TEP or TAPP,is associated with less chronic pain than open repairs.18,19
Accurate long-term follow-up can be difficult to achieve, as many patients undergoing hernia repair are often lost to follow-up.A comparatively high5-year follow-up of72% was achieved,with the majority of these patients attending for clinical examination.The4%of patients who died dur-ing the follow-up was in keeping with the expected death rate for a population of the same age.20Despite a review of the notes in patients who did not complete5-year follow-up identifying no further recurrences,it is possible that addi-tional recurrences were missed as patients sought treat-ment elsewhere.
Pre-peritoneal dissection of both hernial orifices,even in patients with a unilateral hernia,allowed for the detection of incidental hernias in almost10%of patients.Previous studies have quoted this figure to be as high as19%.21Even though the laparoscopic approach may provide superior visual access compared to the open approach,dissection in the absence of a hernia may produce scarring that makes any further surgery on the contralateral side more trouble-some.Dissection in the extraperitoneal plane has also been associated with bladder and bowel injuries,22but no major complications were encountered.Only two patients required conversion to an open procedure and in both instances this was as a result of hernial incarceration.Early postoperative complications were comparable to other studies,4,23with wound infection and urinary retention being the most commonplace.There were two cases of meralgia parasthetica,most probably as a result of tack impingement on the lateral femoral cutaneous nerve,but both resolved without treatment.It is important to remem-ber that excessive lateral tacking can lead to the entrap-ment of this nerve.
Conclusions
Despite the proven short-term benefits of TEP repair,there is limited data regarding the long-term results.This series has achieved a dedicated follow-up of430repairs,demon-strating TEP repair to be a safe and durable procedure with rates of long-term recurrence comparable to those of spe-cialist hernia centres undertaking open repair.24,25
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