Abstract
Background
With the increased use of robotic surgery, robotic transabdominal preperitoneal repair (R-TAPP) has become a commonly used approach for inguinal hernia repair. The laparoscopic totally extraperitoneal repair (L-TEP) has the advantage of not entering the peritoneal cavity; however, it has greater technical difficulty. Robotic surgery has demonstrated superiority over laparoscopy in many surgical settings, but there is limited evidence comparing L-TEP and R-TAPP.
Methods
This was a retrospective review of patients who underwent L-TEP and R-TAPP at Baylor University Medical Center between December 2011 and January 2022. Information on patient demographic characteristics, comorbidities, postoperative complications, hospital length of stay, and postoperative complications requiring a procedure was collected.
Results
A total of 298 patients were analyzed; 245 underwent R-TAPP and 53 underwent L-TEP. Hernia recurrence was significantly decreased in those who underwent R-TAPP (1.2%) compared to L-TEP (9.4%) (P = 0.01). Postoperative pain was also significantly decreased in the R-TAPP group (5.3%) as compared to the L-TEP group (13.2%) (P = 0.01).
Conclusions
With the transition from L-TEP to R-TAPP over recent years, there is limited evidence supporting this change in practice. Our single-center retrospective review demonstrates that R-TAPP is noninferior to L-TEP and has significantly decreased hernia recurrence.
Keywords: Hernia recurrence, inguinal hernia repair, laparoscopic totally extraperitoneal inguinal hernia repair, postoperative pain, robotic transabdominal preperitoneal inguinal hernia repair
Inguinal hernias have remained one of the most common surgical conditions encountered in the United States, with over 1.6 million diagnoses made annually.1 Likewise, inguinal hernia repairs have also remained one of the most common surgery operations in the US, with approximately 700,000 repairs being done annually since 2006.2 Since the first successful inguinal floor reconstruction was described by Edwardo Bassini in 1884, inguinal hernia repairs have undergone rapid evolution in the last century, paralleling a better understanding of the anatomy as well as the advances of available tools for definitive management.3,4 Although there has been tremendous growth since its introduction in the modern era, there remains great debate on the approach that best optimizes patient outcomes, especially in light of emerging technologies such as the introduction of robotic surgery.5
The introduction of laparoscopic techniques in the 1990s revolutionized the approach to inguinal hernia repairs, and by the end of the decade, it was universally accepted that these techniques have better outcomes than traditional open approaches.5,6 Since then, numerous studies have demonstrated the overall effectiveness of laparoscopic inguinal hernia repairs, reporting significantly reduced postoperative pain, faster recovery times, improved recurrence rates, and shorter hospital length of stay, among other metrics.5–7 The two commonly used laparoscopic methods are the transabdominal preperitoneal (TAPP) approach and the totally extraperitoneal (TEP) approach, with studies demonstrating similar outcomes between the two.6–8 Although the two approaches are similar, the transabdominal approach reportedly has higher rates of intraabdominal injuries, and the TEP approach was originally developed in response to concerns about the disruption of the peritoneal cavity.6 In spite of this added protection, the TEP approach can be more technically challenging due to the smaller available working space, one of the difficulties that stimulated the development of robotic approaches for inguinal hernia repair.6,9
With advancements and increased experience in minimally invasive surgery over the last decade, robotic approaches have exponentially taken over inguinal hernia repairs.9 Robotic approaches of both TEP and TAPP are now feasible, although robotic TAPP (R-TAPP) is preferred due to technical factors.9 Despite its rapid adaptation, there is still limited evidence to support the use of robotics over laparoscopy for inguinal hernia repairs.10,11 This is in stark contrast to other surgical specialties, where the use of robots over traditional approaches for hallmark procedures has been supported by several large robotic clinical trials.12,13 To date, only two large studies have been the most impactful in the comparison of robot versus laparoscopy for hernia repairs. These include the multicenter, single-blinded, prospective RIVAL (Robotic Inguinal Versus Transabdominal Laparoscopic inguinal hernia repair) study and the largest meta-analysis comparing robotic and laparoscopic inguinal hernia repairs by Solaini et al.10,11 Both studies found no clear benefit for the use of the robotic approach over the laparoscopic approach in regards to overall complications, postoperative pain, and urinary retention, with added mentions of higher cost, higher rates of surgeon frustration, and longer operative times.10,11 Despite these two larger studies, there is still a paucity of literature comparing the outcomes of two common approaches, L-TEP and R-TAPP, to largely support the transition seen in practice. Only three studies have compared L-TEP and R-TAPP, with overall similar outcomes between the two techniques. In the study by Gundogdu et al, R-TAPP demonstrated better outcomes in overall complications and postoperative pain when compared to L-TEP for bilateral inguinal hernia repairs.14 The studies by Aghayeva et al and Kudsi et al found that long-term postoperative outcomes and recurrence rates were similar between the groups.15,16 With equivocal findings in the few studies to date, the use of one method over the other remains a topic of debate.
The purpose of this study was to evaluate our institution’s experience with the transition from L-TEP to R-TAPP inguinal hernia repairs and provide empirical data on the postoperative outcomes to reflect the change observed in practice.
METHODS
Study design
A research proposal for the study was approved by the Baylor University Medical Center (BUMC) institutional review board. After the successful launch of our database, we performed a retrospective review of all patients who underwent L-TEP and R-TAPP at BUMC in Dallas, Texas by a single surgeon (D.A.) between December 2011 and January 2022. Basic patient demographic information such as age, gender, and body mass index, as well as significant comorbidities at the time of surgery, was collected. The type of hernia repair (L-TEP vs R-TAPP), the laterality (unilateral or bilateral), and any concomitant surgeries were also included. The primary outcomes included postoperative complications (i.e., hernia recurrence, postoperative pain, surgical site occurrences, hospital length of stay) and postoperative complications requiring procedures (i.e., repair of hernia recurrence, drainage of abscess or seroma, hematoma evacuation). Hernia recurrence was defined as any unilateral inguinal hernia recurrence that was diagnosed on physical exam by the surgeon or imaging within the 1-year follow-up period. Postoperative pain included any patient-reported pain or a new or continued pain medication prescription, as there was no validated pain scale in the chart to assess pain objectively. Exclusion criteria were being <18 years of age or being lost to follow up. Informed consent was not necessary due to the retrospective nature of the study.
Operative techniques
Local anesthesia was used with 0.25% bupivacaine hydrochloride in both types of procedures. Skin incisions were closed with 4–0 Monocryl in a subcuticular fashion in both cases.
For the L-TEP inguinal hernia repair, an infraumbilical incision was made and dissected to the anterior fascia. The anterior facial sheath was then incised and the rectus muscle was retracted to gain access to the preperitoneal space. A 12 mm blunt tip trocar with a dissecting balloon was then placed down to the pubic tubercle and a preperitoneal balloon was insulated and subsequently desufflated. The preperitoneal space was insufflated with 15 mm Hg of CO2. Two additional 5 mm ports were placed in a vertical fashion between the umbilicus and suprapubic region. The pubic tubercle was identified, and dissection was carried over Cooper’s ligament laterally, carefully identifying and preserving the spermatic cord structures. Dissection was carried out over Cooper’s ligament to open the space of Retzius, laterally to the space of Bogros until the anterior superior iliac spine was reached. ProLite™ midweight polypropylene mesh (Atrium Medical Corporation, Hudson, NH, USA) was then tacked to the pubic tubercle, Cooper’s ligament, and just lateral to the epigastric vessels using the SecureStrap™ Absorbable Strap Fixation Device (Ethicon, Raritan, NJ, USA). The preperitoneal space was desufflated and the periumbilical fascial incision was closed with 2–0 Vicryl® (Ethicon, Raritan, NJ, USA).
For the R-TAPP inguinal hernia repair, a 5 mm incision was made just left of midline and superior to the umbilicus and a 5 mm OptiView trocar was used to enter the abdomen under direct visualization. The abdomen was insufflated to 15 mm Hg CO2. Two 8 mm robot trocars were placed in a horizontal fashion just superior to the umbilicus. The 5 mm entry trocar was replaced with an 8 mm robot trocar. The robot was then docked. Robotic monopolar scissors and bipolar grasper were used during the dissection, which started by making a peritoneal flap at the anterior superior iliac spine laterally and carrying this over medially to the umbilical ligament, separating the peritoneum from the transversalis fascia. The peritoneal flap was then carried down inferiorly to the pubic tubercle, identifying and preserving the spermatic cord structures. Robotic scissors were replaced by robotic needle driver. A ProGrip™ Laparoscopic Self-Fixating Mesh, Anatomical Design (Covidien, New Haven, CT, USA) was placed in the peritoneal flap and the flap was closed with 2-0 V-Loc™ (Medtronic, Dublin, Ireland) in a running fashion.
Postoperative care
Patients were sent to the postanesthesia unit for recovery. Most patients were discharged on postoperative day zero, and discharge planning was standard with directions for activity and regular diet as tolerated. Patients were followed up in the clinic at 2 weeks, 6 weeks, 6 months, and 1 year postoperatively, where they were reassessed for pain, hernia recurrence, and other complications.
Statistical analysis
Continuous variables were presented as mean and standard deviation or median and interquartile range, while categorical variables were presented as the frequencies and percentages of events. Differences between continuous data were compared by the Student’s t test, while Pearson chi-square or Fisher’s exact tests were used to compare differences in proportion between the groups, as appropriate. All the statistical analyses were conducted with R version 4.0.3 statistical software. All statistical tests were two-sided with a statistical significance level set at P < 0.05.
RESULTS
A total of 298 patients met the inclusion criteria for our study, with L-TEP consisting of 17.7% (n = 53) and R-TAPP consisting of 82.3% (n = 245). Three patients were lost to follow-up and excluded. One surgeon (D.A.) performed all the cases. L-TEP was mostly performed between December 2011 and September 2017, whereas R-TAPP was primarily performed between December 2017 and January 2022, representing the surgeon’s transition from the laparoscopic to the robotic approach over time.
There were no significant differences in patient characteristics and comorbidities between the two groups at baseline (Table 1). Those in the L-TEP group had an average age of 57.4 ± 13.4 years, whereas those in the R-TAPP group had an average age of 60.4 ± 14.7 (P = 0.18). The predominance of male patients in the study reflects the predominance of inguinal hernias in men reported in the literature.
Table 1.
Patient characteristics by type of procedure
| Variable | Laparoscopic TEP (N = 54) | Robotic TAPP (N = 245) | P value |
|---|---|---|---|
| Age, years: mean ± SD | 57.4 ± 13.4 | 60.4 ± 14.7 | 0.18a |
| Gender | 0.95b | ||
| Female | 5 (9.3%) | 22 (9.0%) | |
| Male | 49 (90.7%) | 223 (91.0%) | |
| BMI, kg/m2: mean (SD) | 28.1 (5.4) | 27.5 (5.0) | 0.50a |
| Diabetes | 6 (11.1%) | 27 (11.0%) | 1.00c |
| COPD | 0 (0.0%) | 2 (0.8%) | 1.00c |
| Hypertension | 23 (42.6%) | 104 (42.4%) | 1.00c |
| ESRD | 0 (0.0%) | 3 (1.2%) | 1.00c |
| Tobacco use | 3 (5.6%) | 22 (9.0%) | 0.59c |
| Immunosuppressed | 1 (1.9%) | 16 (6.5%) | 0.33c |
P value based on aStudent’s t test;
bPearson’s chi-squared test;
cFisher’s exact test for count data.
BMI indicates body mass index; COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease; SD, standard deviation; TAPP, transabdominal preperitoneal repair; TEP, totally extraperitoneal repair.
There were no intraoperative complications or surgery-related mortality in either group. There was no significant difference in the length of stay between the two groups. Most patients were discharged in stable condition on the day of their operation. Within the study, only four patients required readmission or had an extended length of stay, but in general, these patients had concomitant surgeries with their inguinal hernia repair. These included one patient in the L-TEP group and three patients in the R-TAPP group. In the L-TEP group, this patient had a concomitant robotic prostatectomy and was ultimately discharged on postoperative day 2. In the R-TAPP group, one patient presented to the emergency department on postoperative day 2 for a brief syncopal episode at home. Workup was overall unremarkable for any postoperative complications, and the patient was observed overnight but ultimately was discharged with no further issues at follow-up. One patient in the R-TAPP group who concomitantly had a robotic unilateral nephrectomy with bilateral inguinal hernia repair required an extended stay for medical optimization. This patient was discharged on postoperative day 8 without any further postoperative complications reported during follow-up. Lastly, one patient in the R-TAPP group underwent concomitant robotic hysterectomy and inguinal hernia repair and was discharged on postoperative day 2.
Between the two groups, the hernia recurrence was significantly decreased in those who underwent R-TAPP (1.2%) compared to those who underwent L-TEP (9.4%) (P = 0.01), as seen in Table 2. For those with inguinal hernia recurrence, the percentage that underwent a surgical repair was also lower in the R-TAPP group (1.2%) than the L-TEP group (7.5%) and approached borderline significance (P = 0.06). Postoperative pain was also reported significantly less frequently in the R-TAPP group (5.3%) as compared to the L-TEP group (13.2%) (P = 0.01). No significant difference was seen in the complications of surgical site infections, seroma, or hematoma formation between the two groups. Overall, the presence of these complications was low for both types of procedures and, when present, there was no difference in the rate at which they required a surgical intervention such as mesh removal, abscess or seroma drainage, or hematoma evacuation. Interestingly, other minor complications not otherwise specified were also significantly higher in those who had undergone L-TEP (11.3%) versus R-TAPP (3.7%) (P = 0.01). These complications included, but were not limited to, numbness, constipation, itching, and mild surgical site drainage, which generally resolved by the 6-week postoperative visit.
Table 2.
Outcomes by type of procedure
| Variable | Laparoscopic TEP (N = 54) | Robotic TAPP (N = 245) | P value |
|---|---|---|---|
| Complication: Surgical site infection | 1 (1.9%) | 1 (0.4%) | 0.33a |
| Complication: Pain | 12 (22.2%) | 18 (7.3%) | <0.01a |
| Complication: Recurrence | 5 (9.3%) | 4 (1.6%) | 0.01a |
| Complication: Seroma | 1 (1.9%) | 16 (6.5%) | 0.33a |
| Complication: Hematoma | 3 (5.6%) | 7 (2.9%) | 0.39a |
| Other complication | 8 (14.8%) | 11 (4.5%) | 0.01a |
| Complication requiring procedure | 4 (14.3%) | 11 (7.7%) | 0.28a |
| Procedure for abscess drainage | 0 (0.0%) | 1 (0.4%) | 1.00a |
| Procedure for mesh excision | 0 (0.0%) | 2 (0.8%) | 1.00a |
| Procedure for recurrent hernia | 4 (7.4%) | 5 (2.0%) | 0.06a |
| Procedure for drainage of seroma | 0 (0.0%) | 2 (0.8%) | 1.00a |
| Procedure for hematoma evacuation | 0 (0.0%) | 1 (0.4%) | 1.00a |
| Length of stay: median (IQR) | 0.0 (0.0, 0.0) | 0.0 (0.0, 0.0) | 0.72b |
| Length of stay ≥ 1 day | 1 (1.9%) | 3 (1.2%) | 0.55a |
P value based on aStudent’s t test;
bPearson’s chi-squared test.
IQR indicates interquartile range; TAPP, transabdominal preperitoneal repair; TEP, totally extraperitoneal repair.
DISCUSSION
Despite the rapid adoption of robotic-assisted inguinal hernia repairs, limited studies have compared the outcomes between L-TEP and R-TAPP to justify the transition seen in practice. In the three studies to date comparing the methods, there has not been supporting evidence for R-TAPP as observed in clinical practice by many surgeons.14–16 To our knowledge, this is the first study to demonstrate that R-TAPP has significantly decreased hernia recurrence, postoperative pain, and complication rates compared to L-TEP for inguinal hernia repairs in a single-center retrospective review. This study also demonstrated that the transition from L-TEP to R-TAPP is safe and feasible, with noninferiority for surgical site occurrences or those that require intervention.
Postoperative pain following inguinal hernia repairs is a major issue and can significantly impair quality of life and thus delay return to function in postsurgical patients.17 It is reported that persistent pain following inguinal hernia repairs is seen in about 2% to 18% of patients, but despite its associated disability, consensus for pain management strategies is still lacking; thus, lowering patients’ overall risk remains a primary goal.17–19 In the few studies mentioned previously, including a recent meta-analysis on robotic versus laparoscopic inguinal hernia repair, there were no significant differences in postoperative pain between L-TEP and R-TAPP.11 In our single-center retrospective review, we found a statistically significant decrease in the rate of postoperative pain in the R-TAPP group. Given the extraperitoneal approach in L-TEP, it would be expected to lead to less postoperative pain with no peritoneal violation or pneumoperitoneum. However, even with peritoneal violation and pneumoperitoneum, the decreased postoperative pain observed in R-TAPP may be due to less torquing of instruments. Previous studies have demonstrated that absorbable tacks do not significantly contribute to postoperative pain20; however, the decreased postoperative pain in the R-TAPP group may also be due to the lack of fixation with tacks.
Despite the advent of new operative techniques as well as the incorporation of mesh for inguinal hernia repairs, hernia recurrence remains one of the most common postoperative complications.21 The three studies to date, including the recent meta-analysis comparing L-TEP and R-TAPP, have not shown any significant difference in hernia recurrence at 1 year follow-up.11 Our single-center retrospective review is the first to demonstrate a significantly decreased hernia recurrence for the R-TAPP group (1.6%) compared to the L-TEP group (9.3%) (P = 0.01). We also found a nonsignificant decrease in hernia recurrence requiring reoperation, as seen in Table 2. The recurrence rate for L-TEP reported in the literature, ranging from 1% to 32%, has been found to differ significantly between surgeons and hospitals, indicating that surgeon experience and proficiency play a significant role in recurrence for the extraperitoneal approach.22 The decreased hernia recurrence in the R-TAPP group may be due to the preperitoneal placement of the mesh rather than the extraperitoneal placement, surgeon proficiency, or type of mesh. There have been limited studies evaluating hernia recurrence between polypropylene and ProGrip™ mesh, especially in minimally invasive surgery techniques.23–25 One prospective randomized study demonstrated that the ProGrip™ mesh has similar performance to polypropylene mesh in TEP26; however, the differences seen in hernia recurrence may be due to the type of mesh used.
The main limitation of our study is the single-surgeon, single-center retrospective design. However, the primary surgeon of the study had several years of experience for both procedures and demonstrated proficiency for the different approaches prior to the collection of our patient data. The heterogeneity of this study in comparing both laparoscopic and robotic approaches and TEP versus TAPP is a major limitation, but it is important to study given the transition in practice from L-TEP to R-TAPP. There is a disproportionate sample size between the two groups due to a transition in practice from L-TEP to R-TAPP, which may limit the outcomes gathered from the L-TEP group. Another limitation is the use of absorbable tacks in the L-TEP group and no mesh fixation in the R-TAPP group; however, this represents the advancements in meshes over time with current self-fixating meshes. During the time that L-TEP was being performed in this study, the fixation of the mesh was still controversial but was performed to prevent mesh migration. More recent studies have demonstrated that mesh fixation does not lead to a reduction in hernia recurrence and thus mesh fixation has been eliminated by many surgeons in more recent practice.27 No validated pain scale was used due to the retrospective nature of this study. Operative time was not reliably reported in the electronic medical record for the patients in this study and thus a statistical analysis could not be performed. Given the increased experience and use of robotic-assisted surgery, future studies should focus on operative times, costs, a validated pain metric, and randomized control trials to confirm these findings.
In conclusion, this is the first study to demonstrate that R-TAPP has significantly decreased hernia recurrence and other complications compared to L-TEP for inguinal hernia repairs in a single-surgeon, single-center retrospective review. Our study demonstrates that R-TAPP is safe and feasible with noninferior surgical site occurrence outcomes when compared to L-TEP.
Funding Statement
Dr. David Arnold serves as a proctor and provides lectureship for Intuitive Surgical, for which he receives compensation. The remaining authors have no competing interests to declare. The authors report no funding. Data supporting the findings of this study are available from the corresponding author on request.
Disclosure statement
Dr. David Arnold serves as a proctor and provides lectureship for Intuitive Surgical, for which he receives compensation. The remaining authors have no competing interests to declare. The authors report no funding. Data supporting the findings of this study are available from the corresponding author on request.
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