Modified Open Anterior Preperitoneal Repair

Abstract

Background and Objectives:

Modified anterior preperitoneal (mAPP) repair for inguinal hernia (IH) was compared with Lichtenstein repair (LR) and laparoscopic transabdominal preperitoneal (TAPP) repairs.

Methods:

IH patients, after exclusions and subsequent matching for age, type, and extent of hernia, were assigned randomly for mAPP, LR or TAPP repair. The same surgical team performed all operations. Data of predefined endpoints for all the three groups were statistically compared.

Results:

One hundred thirty-five patients underwent mAPP, 91 patients LR, and 181 patients TAPP. The operating time for both unilateral and bilateral hernias in the mAPP group was significantly shorter than in LR and TAPP groups. mAPP patients were discharged in significantly less time than LR patients but later than TAPP patients. Postoperative visual analog scale (VAS) score at 24 hours in the mAPP patients was significantly less than LR but at 48 hours the difference was equivocal. But VAS score after mAPP at 24 and 48 hrs was more than in TAPP patients. However, the pain score across all the three groups was similar at 7 days. There was no surgical site infection (SSI) or mesh infection in any patient. Chronic postoperative inguinal pain was seen less often after mAPP than after LR but was least in TAPP patients. Recurrence across all the three groups was not much different.

Conclusion:

mAPP appears to be a better choice for open IH repair than LR and matches the advantages of Laparoscopic repairs.

INTRODUCTION

With the endoscopic or laparoscopic inguinal hernia repair (LIHR), gaining increasing popularity and acceptance, the greatest casualty has been the open IH repairs. Among the open repairs, the two most performed procedures are the current gold standard Lichtenstein repair (LR) and Modified Bassini's repair.

Shouldice repair, although suggested as the preferred herniorraphy, is less commonly performed because of technical issues and shortcomings of non reproducibility of results by the average surgeon.

Unfortunately, both LR and modified Bassini repair suffer from well recognized disadvantage of Chronic postoperative inguinal pain (CPIP) or inguinodynia, attributable to the inguinal canal dissection. LR, in addition, can be faulted for violating Pascal’s principles, by placing the mesh over the posterior wall of the inguinal canal. Even the modified Bassini repair, suffers from a major contravention of the anatomical and physiological inguinal tenets, because the approximation of the arching transversus abdominis and internal oblique muscles to the inguinal ligament, creates undue tension at the posterior inguinal wall and abolishes its shuttering mechanism.

Even LIHR has well recognized drawbacks of a long learning curve because of difficult anatomy, higher cost, and of course, potential for major adverse events. The drawbacks are still there, even today 32 years after the first LIHR was described in 1993 by Arregui¹ and, are the probable reasons why most surgeons are still performing open IH repairs. A recent study on 390,777 patients showed that LIHR was performed for 65.5% of bilateral inguinal hernias, 31.3% of recurrent hernia repairs but only in 17.1% of primary unilateral inguinal hernias.²

An open transinguinal preperitoneal (PP) space approach with minimal inguinal canal dissection, would circumvent the technical short comings of LIHR, but mesh placement in the same plane would provide equal benefit by reinforcing all the potential hernial sites at the Fruchaud’s orifice, namely inguinal, external supravesical, femoral and obturator hernial sites. We described this repair in 2006 and we called it a modified anterior preperitoneal repair (mAPP).³ This repair placed a flat polypropylene mesh, through the deep inguinal ring, in the preperitoneal space, like in a laparoscopic repair. In 2007 we reported a modification of this approach, which further minimized the inguinal canal dissection.⁴ Later the same anterior transinguinal approach, was variously labeled, as transinguinal preperitoneal (TIPP and MAPP) approach.^5–7

METHODOLOGY

This was a prospective, single-center study, conducted in a teaching hospital, over a period of 4 years (excluding the Covid years of 2020 and 2021). Permission of ethics committee was granted. Patients were informed of the options and the study characteristics and variables, and provided written informed consent. Exclusions included, congenital hernias, patients less than 18 years of age, complicated hernias (obstructed and strangulated), recurrent hernias, and patients with decompensated cardiac disease, airway diseases, or other comorbidities relegating the patient to be classified as grade 3 or 4 by the American Society of Anesthesiologists classification.

A total of 407 patients were matched for age, body mass index (BMI) (basal metabolic rate), and extent of IH, and given the option of selecting a procedure or otherwise were randomly assigned to one of the three operative groups, namely mAPP repair, LR, or TAPP repair. Patients of all the three groups had operations under spinal anesthesia and sedation, by the same surgeon and his team.

Hernial sac management, in all the three procedural groups, was uniform and depended on the size of the sac. Funicular and bubonocele sacs were completely mobilized and reposited back into the PP space. Scrotal sacs were partially mobilized and transected about 2 – 3 cm distal to deep inguinal ring (DIR). The proximal end was ligated and reposited back into the PP space. The distal remaining sac was not mobilized, and its transected end was left open.

The mesh used in all repairs, was a monofilament, knitted, light weight (45 g), 0.43 mm thick polypropylene Mesh (Prolus lite), with a pore size of 1.3 × 1.0 mm. Size of mesh used for mAPP and TAPP, was 12 × 15 cm but for LR, mesh was cut to size based on the dimensions of the posterior inguinal canal wall with minimum 1 – 2 cm overlap on all sides.

mAPP was performed as previously described.^3,4 The important steps include limited proximal dissection of the sac in the inguinal canal and entering the preperitoneal (PP) space, through DIR. The entry into the PP space is helped by lifting and medially retracting the medial crus of the DIR, along with the inferior epigastric vessels (IEV), with the help of a 0.5 inches Deaver’s retractor. The forefinger is then introduced between the sac and the vas deferens. This ensures correct entry into the avascular PP space. It is important to remember and emphasize that all the vessels in the subinguinal Retzius and Bogros space lie between the two anterior layers of the transversalis fascia. Behind the second layer is the true avascular PP space and lifting the medial crus of DIR with the IEV, would ensure that the finger enters the avascular PP space. Hence blunt finger dissection in this space, in this procedure, hardly ever causes bleeding. To create adequate space for the mesh to be placed in an angle iron configuration, blunt finger dissection is easily continued medially to the pubic symphysis, laterally 3 cm beyond DIR, superiorly 3 – 4 cm cranial to arching fibers of internal oblique and transversus abdominis muscles and inferiorly on to the surface of the psoas major muscle. The cigarette-like rolled-up mesh is inserted through the DIR, unruffled, and positioned in the PP space, in an angle iron fashion from the undersurface of the anterior abdominal wall and extending onto the surface of the psoas muscle just like in a LIHR. The retractor is removed, and the DIR returns into position and size. The mesh is never fixed. The only sutures that may be required are interrupted 2-0 polypropylene sutures, placed medial to the cord, as in Lytle’s repair.⁸ These sutures help by narrowing a preexisting enlarged DIR, because of a large hernia and, in keeping the obliquity of the canal by pushing the cord more laterally. Optionally, in large direct IH, with a very weak and loose posterior inguinal wall, few interrupted, reinforcing, double breasting sutures can strengthen the TF floor.

LR and TAPP were performed according to standard techniques. In the LR repair, the customized mesh, according to the size of the posterior inguinal wall, was anchored with the help of continuous 2-0 polypropylene suture, to the arching fibers of IO and TA muscles above and inguinal ligament below. Medially the suture picked up the tissue just next to the pubic tubercle. Laterally the mesh was fish-tailed, to encircle the cord. In TAPP the peritoneal flaps were approximated, either with intracorporeal continuous suturing or with absorbable tacks.

The end points of study were, operating time, peroperative complications, assessment for early acute post operative inguinal pain (APIP) at 24 h, 48 h, and end of first week by VAS (visual analog scale), time to discharge (TTD), chronic post operative inguinal pain (CPIP) or inguinodynia considered as pain persisting for 3 or more months, and recurrence rate (RR) up to a follow-up of 3 years (Figure 1). For the 3-year follow-up, the patients were seen in person or contacted by phone.

Figure 1.

Study patients flow chart.

We compared the results of mAPP repair with LR and mAPP with TAPP repair. The analysis was based on the original number of patients in each group. We completed the data analysis using Prism 9 (GraphPad) software by using unpaired t test with Welch's correction.⁹ CPIP and recurrence figures were compared using the χ² calculator for 2 × 2. A P-value < 0.05 represented a statistically significant result.

RESULTS

A total of 135 patients with 161 IH had mAPP repair, 91 patients with 112 IH had LR, and 181 patients with 215 IH had TAPP repair. The demographic data is shown in Table 1. Most patients in all three groups had unilateral, indirect, funicular IH. There was no significant difference in the mean age and the BMI of the patients among the three groups. Females accounted for less than 1% of all patients.

mAPP vs LR: The operating time for both unilateral and bilateral repairs was significantly less with mAPP as compared to LR (Table 2). The post operative VAS score at 24 h after mAPP was also significantly less than after LR but there was no difference after 48 h. mAPP patients were discharged significantly earlier than those after LR (3.03 ± 0.075 vs 4.26 ± 0.092, p ≤ 0.001) (Table 2). CPIP and recurrence up to a 3-year follow-up, occurred in more patients undergoing LR but was not significantly different from mAPP patients.

Table 2.

Preoperative and Postoperative Data

	TIPP	LR		TAPP
	135 Patients	91 Patients	P-value	181 Patients	P-value
	161 Hernias	112 Hernias	TIPP vs LR	215 Patients	TIPP vs TAPP
Operating time (mins) Mean ± SD
U/L (patients)	26.71 ± 8.174	30.25 ± 9.537	<0.009 S*	36.45 ± 11.898	<0.001 S*
	(109 patients)	(70 patients)		(147 patients)
B/L (patients)	44.9 ± 10.242	51.67 ± 11.527	<0.0386 S*	55.83 ± 9.69	<0.001 S*
	(26 patients)	(21 patients)		(34 patients)
Complications
Inferior epigastric vessel injury	–	–		2
SSI	–	–		–
Mesh infection	–	–		–
Seroma/hematoma	8 (5.9%)	6 (6.59%)	0.896 NS	15 (8.29%)	0.42 NS
VAS pain score
24 hrs post op.	2.85 ± 0.0817	3.96 ± 1.445	<0.001 S*	2.55 ± 0.058	<0.0001 S*
48 hrs post op.	1.55 ± 0.838	1.62 ± 0.834	0.336 NS	1.27 ± 0.055	<0.0001 S*
TTD (days)	3.03 ± 0.075	4.26 ± 0.092	<0.001 S*	2.16 ± 0.071	<0.001 S*
Pain ≥ 3 months post op	3 (2.2%)	6 (6.5%)	0.099 NS	1 (0.55%)	0.189 NS
Recurrence (FU 3 yrs)	3 (2.2%)	3 (3.3%)	0.612 NS	4 (2.21%)	0.99 NS

U/L, unilateral; B/L, bilateral; BMI, body mass index; SD, standard deviation; VAS, visual analog scale; S*, significant; NS, not significant; SD, standard deviation; VAS, Visual analog scale; TIPP, transinguinal preperitoneal; TAPP, transabdominal preperitoneal; SSI, surgical site infection; TTD, time to discharge; FU, follow-up.

mAPP vs TAPP: The operating time for both unilateral and bilateral repairs was significantly less with mAPP as compared to TAPP repairs (Table 2). The VAS score after mAPP was significantly more both at 24 and 48 h after surgery, but the score by the end of the first week was comparable. Patients after mAPP were discharged significantly later than after TAPP (3.03 ± 0.075 vs 2.16 ± 0.071, p ≤ 0.001). CPIP was less in TAPP group but not significantly different from the mAPP group and recurrence rate, was also not significantly different between the two groups (Table 2).

IEV injury occurred in two patients with TAPP and was managed with the Harmonic scalpel. Seroma or hematoma formation was the only other postoperative event seen in patients of all the three groups, but difference in incidence across the three groups was not significantly different (Table 2).

DISCUSSION

We have been performing the mAPP approach (now also labelled as TIPP), since the late 1990s, more than 25 years now, as an alternative to the then recently introduced LIHR. We had reported it for the first time in 2006 as mAPP.² The approach was mainly motivated by the limitations with the endoscopic approach, which had to do with the long learning curve, primarily because of the difficult PP inguinal anatomy which had to be seen and understood from an absolutely new perspective, the high cost involved and of course the need for general anesthesia (GA) in all patients. The first two drawbacks exist even today but are more manageable while the GA is no longer essential and most of the LIHR can be safely done under regional anesthesia, as shown by us and others.¹⁰ We have been performing almost all our LIHR under regional anesthesia. Having gained enough expertise with mAPP, we decided to further minimize the dissection in the inguinal canal and so shifted to a smaller incision and less dissection, which we reported in 2007.⁴ The issue of journal Hernia, in which our method was published in 2006, also had an article by Pelissier.⁵ This article also detailed an approach similar to ours and done in much the same way as our method. The Pelissier approach was picked up for a number of citations and is often considered as a benchmark for TIPP. The Pelissier method needed a special low weight 16.0 × 9.5 cm polypropylene mesh with a recoil ring and marketed as Polysoft by Bard.⁵ But for reason unknown, our similar methodology, reported in that same issue, was never picked up nor mentioned subsequently. Although our method of mAPP, through the DIR in all patients, already reported by us twice in 2006 and 2007, was later incorrectly reported as a new method of TIPP.^6,7 The only difference between ours and most of the anterior TIPP reports was of the mesh. While we were, and are, still using a simple flat light weight PP mesh, 10 × 15 cm with the mesh fish tailed laterally and positioned in an angle iron fashion, covering the psoas below and posterior under surface of the inguinal region above, most of the other studies use Polysoft PP mesh with a rigid peripheral ring. In addition to the use of specially prefabricated PP mesh, use of special instruments have been reported in most of the studies.^5–7 We do not use any special instruments and use ordinary .5-in wide Deaver retractors.

Previously we compared mAPP and TEP IH repairs^3,4 and found that the TEP repair of IH required significantly longer operating time and had significantly more peritoneal breaches but the hospital stay was significantly shorter. The neuralgia and recurrence rates among the mAPP and the TEP group was not different.The conclusion was that mAPP matches the results of TEP IH repair and should be the favored option for open IH management. This study was necessary because the place value of our method of TIPP cannot be ascertained nor designated without also comparing it with other LIHR namely TAPP and with the present day gold standard, open LR.

TIPP vs LR

Our operating times for unilateral and bilateral TIPP repairs, were significantly less than the corresponding times for LR (Table 2). This seems to agree with another similar report of significantly shorter times for TIPP as compared to LR¹¹ (Table 3). Comparable operating times for unilateral TIPP were also reported by others.^12–14 However, contrasting figures of longer operating time for TIPP, have also been reported.^15,16 Unfortunately the TULIP trial, the largest trial comparing TIPP with LR focused on long term results and did not report on the comparative operating time between TIPP and LR¹⁷ (Table 3).

Table 3.

Operating Times, Transinguinal Preperitoneal vs Lichtenstein Repair

Study	Year	TIPP (min)	LR (min)
Koning11	2012	34.1 ± 9.9 (n = 143)	39.9 ± 12.0 (n = 159)
Berrevoet12	2009	22 (range 14 – 37)	Not done
Bokkerink, ENTREPPMENT trial13	2021	25 (IQR = 20 – 31)	Not done
Sajid14	2013	Random effect model in meta-analysis
		no difference
Hamza15	2009	54.5 ± 13.2	34.21 ± 21.5
Williams16	2013	46.9 ± 69.2	Not done
Present study, Sinha et al.	2023	U/L 26.71 (±8.174)	U/L 30.25 (±9.537)
		B/L 44.9 (±10.242)	B/L 51.67 (±11.527)

TIPP, Transinguinal preperitoneal; LR, Lichtenstein repair; U/L, unilateral; B/L, bilateral; n, no. of patients; IQR, shows 25%–75% interquartile range.

Among the other important end points was the incidence of APIP and CPIP. We found that APIP was significantly less after TIPP than after LR at 24 h, but this difference disappeared at and after 48 h (Table 2). Other studies on APIP have found less pain in TIPP vs LR at 24 and 48 h after surgery.^15,17 After LIHR the early pain has been mentioned to be most severe on first post operative day.¹⁸

CPIP is an important end point in almost all comparative studies between TIPP and LR. Unfortunately the definition of CPIP has a number of cut off timelines, making interpretation of reports difficult. From among a host of different definitions of CPIP, probably the most accepted is the one put forward by the International Association for the Study of Pain, which defines chronic pain as, “pain that persists at the surgical site and nearby surrounding tissues beyond 3 months.”¹⁹ The exact cause or causes of CPIP are still unclear but the suggestions include, direct nerve irritation by the mesh or nerve injury by sutures²⁰ or by tacks in LIHR,²¹ late scarring at the operated inguinal site,²² or mesh induced inflammatory reaction.²³ CPIP, after all IH repairs has been collectively reported with an overall mean incidence of 11% in the HerniaSurge report,²⁴ 3.5%, at 1 year post TIPP in the TULIP trial,¹⁷ and as 1.4% in the later ENTREPPMENT trial¹³ (Table 4). Other noncomparative, studies have also reported CPIP incidence, varying from 5% to 20.62%^7,11,27 at up to1 year after TIPP. Among the comparative studies, TULIP trial¹⁷ found no difference in CPIP after TIPP and LR at 85 months postoperative. But others have reported a higher incidence of pain after LR vs TIPP^11,26 (Table 4). Also there are studies where CPIP did not occur at all in any of the TIPP or LR patients.^15,29 Comparing our results, the highest incidence of CPIP was in the LR group and least in the TAPP group, but the difference in incidence of CPIP, between TIPP and LR was not significant (Table 4).

Table 4.

Chronic Postoperative Inguinal Pain, Transinguinal Preperitoneal vs Lichtenstein Repair

Study	Year	FU Period	TIPP	LR
TULIP trial17	2019	1 y	3.5%	12.9%
		85 m	No difference
Bokkerink, ENTREPPMENT trial13	2021	1 y	1.4%	X
Willaert26	2012	3 m	2.77%	17.85%
Koning11	2012	3 m	3.49%	12.57%
Marc Soler7	2017	3 m	11/97 (11.34%) VAS (4 – 8)	X
Pelissier25	2008	21.9 m (11.6 – 29.4)	5% − 7%	X
Anderson27	2017	6 m	14.5%	X
	2017	1 y	8.7%	X
Hamza15	2010	1 y	0	0
Karatepe28	2008	1 y	0	0
Present study, Sinha et al	2023	≥ 3 m	3 (2.2%)	6 (6.5%)

TIPP, transinguinal preperitoneal; LR, Lichtenstein repair; TAPP, transabdominal preperitoneal; FU, Follow up period; X, not reported; m, months; y, years.

The great variation in the follow-up period in different reports makes interpretation of the recurrence rate (RR) difficult. The TULIP trial¹⁷ reported no significant difference in the RR between TIPP and LR, after a median follow up of 85 months as also other studies with follow-up periods of up to more than 7 years^11,29,30,31 (Table 5). In contrast there were studies where there was no recurrences in either TIPP or LR patients after a FU of up to 70 months.^15,27 A noncomparative TIPP study found recurrence rates between 1% to 2%, after a FU of 21.9 months.²⁵ Our recurrence rate, after a FU of 36 months, was maximally seen after LR (3.3%), but the difference in RR among the three groups was not statistically significant (Table 5).

Table 5.

Recurrence Rates, Transinguinal Preperitoneal vs Lichtenstein Repair

Study	Year	FU Period	TIPP	LR
TULIP trial17	2019	85 m (74 – 117)	1/7%	3.8%
Pelissier25	2008	21.9 m (11.6 – 29.4)	1.2% (2/171 patients)	X
Koning11	2012	12 m	1.3% (2/143)	2.52% (4/159)
SOFTGRIP trial29	2022	1 y	Overall, 2.6% NS
Neinhuijs30	2007	5 y	Overall, 8.3% NS
Neinhuijs31	2015	7.6 (6.9 – 9.2)	1/90	3/89
Hamza15	2010	1 y	0	0
Karatepe28	2008	70 m	0	0
Soler7	2017	2 y	0	X
Present study, Sinha et al	2023	3 y	3 (2.2%)	3 (3.3%)

TIPP, transinguinal preperitoneal; LR, Lichtenstein repair; TAPP, transabdominal preperitoneal; FU, follow-up period; X, not reported; m, months; y, years.

TIPP vs TAPP

It is very hard to find comparative studies between anterior TIPP and TAPP repair for IH. While Sarhan³² and Li³³ found a significantly longer time for TIPP than TAPP, Hamza¹⁵ in his four-arm study showed a significantly longer operating time for TAPP than TIPP (Table 6). Our findings are in concurrence with those of Hamza, with shorter operating time for TIPP (Table 2). APIP was reported as most severe on the first postoperative day after TAPP and TEP.¹⁸ Our study showed that the early pain was significantly less in TAPP as compared to TIPP and LR at 24 and 48 h (Table 2). However, the difference in APIP between TAPP and TIPP was equivocal at the end of the first week post operative. Similar results of significantly less pain in TAPP and also LIHR combined as compared to TIPP were reported by Hamza.¹⁵ Logically, CPIP should be less after laparoscopic repairs, because the inguinal area is not dissected and thus chances of nerve injury in the inguinal canal would be less. But we did not find any significant difference in CPIP between TAPP and TIPP repair. Although, significantly less incidence of CPIP was reported in TAPP patients as compared to TIPP patients by both Li³³ and Sarhan,³² while Hamza did not report any CPIP in his TIPP patients but in his TAPP group there was 1 patient with CPIP (Table 7).

Table 6.

Operating Times, Transinguinal Preperitoneal vs Transabdominal Preperitoneal

Study	Year	TIPP	TAPP	LIHR (TEP + TAPP)
Sarhan32	2016	64.1 ± 20.1	37.8 ± 18.4
Li33	2013	U/L 64.02 ± 35.12		29.57 ± 17.96
		B/L 135.38 ± 52.43	X	48.52 ± 22.93
Hamza15	2009	54.5 ± 13.2	96.12 ± 22.5
Present study, Sinha et al	2023	U/L 26.71 (±8.174)	U/L 36.45 (±11.898)
		B/L 44.9 (±10.242)	B/L 55.83 (±9.69)

TIPP, transinguinal preperitoneal; TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal repair; LIHR, laparoscopic inguinal hernia Repair; U/L, unilateral; B/L, bilateral; values are Mean ± SD; n, no. of patients; X, not reported.

Table 7.

Chronic Post Operative Inguinal Pain, Transinguinal Preperitoneal vs Transabdominal Preperitoneal

Study	Year	FU	TIPP	TAPP	LIHR (TEP + TAPP)
Sarhan32	2016	1 y	7%	1%	X
Hamza15	2010	1 y	0	4% (1/25)	–
Li33	2013	>3 m	7.31% (37/506)	X	1.35% (16/1185)
Present study, Sinha et al	2023	≥3 m	3 (2.2%)	1 (0.55%)	–

TIPP, transinguinal preperitoneal; TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal repair; LIHR, laparoscopic inguinal hernia repair; FU, follow-up period; m, month; y, years; X, not reported.

The RR, between TIPP and TAPP, did not differ significantly in either our study or similar other studies^15,32,33 (Table 8). We used the telephonic method of tracking the patient up to a period of 3 years for the RR. This is a validated method of assessment regarding the recurrence rates and has been labelled as PINQ-PHONE (Post-INguinal-repair-Questionnaire by telePHONE).³⁵

Table 8.

Recurrence Rates, Transinguinal Preperitoneal vs Transabdominal Preperitoneal

Study	Year	FU	TIPP	TAPP	LIHR (TEP + TAPP)
Sarhan32	2016	1 y	1%	1%	X
Hamza15	2010	1 y	--	4% (1/25)	X
Li33	2013	2 y	1.19% (6/506)	X	0.51% (6/1185)
Present study, Sinha et al	2023	3 y	3 (2.2%)	4 (2.21%)	X

TIPP, transinguinal preperitoneal; TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal repair; LIHR, laparoscopic inguinal hernia repair; FU, follow-up period; y, years; X, not reported.

Among the other per and postoperative parameters, Inferior Epigastric vessel injury occurred in only 2 patients, in the TAPP group but was managed easily with the Harmonic scalpel. Injury to IEV has also been reported by others, in both TIPP and LIHR procedures (TEP and TAPP) and was managed intraoperatively in all patients without conversion.^32,33 Postoperative seroma or hematoma was seen in patients in all three groups, but the difference was not significant (Table 2). Similar incidence of seroma after TIPP and TAPP has also been reported by others.^32,33 Surgical site infection (SSI) or mesh infection did not occur in any of our patients. Although SSI was reported in other studies but without significant difference among the procedures.^13,32,33

Open approaches to the inguinal PP space, from the posterior aspect as in the Ughary³⁵ approach or the original Kugel³⁶ approach or the more recent MOPP approach⁷ are difficult and time consuming and may require a large incision. Going through all layers of the anterior abdominal wall and then approaching the PP is at best a daunting task, and the probable reason for not being widely accepted. Anterior approaches like Nyhus³⁷ and Rives Stoppas³⁸ techniques require large incisions. The anterior TIPP approach, in contrast, is a much easier proposition and in our institution, easily reproducible even at the hands of residents.

CONCLUSION

mAPP repair of IH is a practical and a better option to LR in terms of operating time, TTD and CPIP, while the recurrence rates are the same. In addition, unlike in LR, it combines the extra advantage of LIHR by the PP mesh placement covering the whole Fruchaud’s orifice. As compared to TAPP, while the operating time is less in mAPP but TTD and VAS score at 24 h and 48 h are less after TAPP. CPIP and recurrence rates are comparable between mAPP and TAPP repair. Familiar anatomy, shorter operating times, easier to learn, and favorable outcomes, all make it a pragmatic open repair alternative to LR and a strong challenger to TAPP.

Table 1.

Demographic Data

	TIPP	LR	P-value*	TAPP	P-value*
		TIPP vs LR	TIPP vs TAPP
Patients/hernias (N = 407/488)	135 pts/161 hernias	91 pts/112 hernias	–	181 pts/215 hernias
U/L patients	109	70	–	147
B/L patients	26	21	–	34
Direct	31 hernias (19.25%)	18 hernias (16.07%)	–	53 hernias (24.65%)
Indirect	130 hernias	94 hernias		162 hernias
Bubonocele	56 hernias (34.8%)	42 (37.5%)	–	70 (32.6%)
Funicular	85 (52.82%)	52 (46.4%)		113 (52.6%)
Scrotal	20 (12.4%)	18 (16.1%)		32 (14.8%)
Age (years)
Mean ± SD	48.78 ± 16.545	51.44 ± 17.789	NS (0.251)	45.86 ± 12.931	NS (0.079)
BMI (Kg/m2)
Mean ± SD	26.34 ± 3.52	26.57 ± 3.13	NS (0.948)	25.62 ± 3.99	NS ± 0.096
Sex
M	132	91		180
F	02	–		01

*P < 0.5 is significant.

Pts, patients; U/L, unilateral; B/L, bilateral; BMI, body mass index; SD, standard deviation; TIPP, Transinguinal preperitoneal; LR, Lichtenstein repair; TAPP, transabdominal preperitoneal; NS, not significant.