Inguinal Hernia Repair: Comparative Study between TEP versus Extended Totally Extraperitoneal

Abstract

Background:

Inguinal hernia repair is a common surgical procedure, with laparoscopic techniques offering advantages over open surgery. The extended Totally Extraperitoneal (eTEP) technique provides a larger working space compared to the traditional Totally Extraperitoneal (TEP) approach, potentially improving outcomes.

Material and Methods:

A prospective study was conducted comparing eTEP and TEP techniques for inguinal hernia repair at Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune. Forty patients (20 in each group) aged 15-65 with uncomplicated inguinal hernias were included. Surgical procedures were performed based on patient preference. Data on surgical duration, pain scores, hospital stay, and complications were collected and analyzed using statistical methods.

Results:

eTEP surgery had a significantly shorter mean duration (48.70 ± 7.505 minutes) compared to TEP surgery (74.20 ± 7.78 minutes; p = 0.00). Patients undergoing eTEP experienced lower mean pain scores (3.75 ± 0.55) compared to those undergoing TEP (5.15 ± 0.745; p = 0.00). Hospital stay following eTEP surgery was shorter (1.70 ± 0.657 days) than following TEP surgery (3.65 ± 1.137 days; p = 0.00). eTEP had lower incidences of hematoma and surgical emphysema but higher seroma complications. TEP surgeries were associated with more post-operative complications and a higher likelihood of requiring conversion to open surgery.

Discussion:

The eTEP technique offers several advantages over TEP, including shorter surgical duration, less post-operative pain, and shorter hospital stays. However, TEP had more complications related to seroma. Individual patient factors and surgeon experience should guide the choice of technique.

Conclusion:

The eTEP technique appears to be a promising option for inguinal hernia repair, offering advantages over TEP in terms of surgical outcomes. However, further studies are needed to evaluate long-term outcomes and complication rates comprehensively.

INTRODUCTION

Protrusion of abdominal contents through inguinal canal is known as inguinal hernia. Its symptoms are present in 66% among those having it, which includes pain or discomfort while coughing, exercises. It usually worsens all the day and improves on lying down. Bulged areas increased in size while bending down. Right side inguinal hernias are common than the left side.[1] Direct inguinal hernia is less frequent occurring hernia (~25%–30% of inguinal hernias) and often present in men above 40 years, men having eight time higher incidence of hernia in comparison with women.[2] Surgical management usually not recommended in minimal symptomatic hernias, watchful waiting is advised in those cases. While in others surgical management includes open repair, use of mesh or laparoscopic repair. Every year approximately 20 million cases of both inguinal and femoral hernia repair surgery are performed, while the UK only reports approximately seventy thousands hernia repair.[3]

The preferred method for repairing almost all inguinal hernias since 1996 has been the endoscopic extraperitoneal approach.[4] This technique involves making small incisions away from the site of the hernia and using a laparoscope to visualize the hernia and surrounding structures. The laparoscope is inserted through one of the incisions, while other instruments are inserted through the remaining incisions to perform the repair. The endoscopic extraperitoneal approach offers a major advantage over traditional open surgery by not requiring entry into the abdominal cavity, thereby reducing the risk of complications such as intestinal and vascular injuries and herniation at trocar sites. Furthermore, this approach can be performed under general anesthesia, or intravenous sedation with regional anesthesia, making it a safe and convenient option for patients.[5,6]

In addition to its safety profile, the endoscopic extraperitoneal approach provides an excellent view of local structures, allowing for precise and accurate repair of the hernia.[7,8] The Rives-Stoppa technique serves as the basis for the extraperitoneal approach, but the classically totally extraperitoneal (TEP) technique has several drawbacks, such as limited space for dissection and mesh placement, restricted port placement, possible intolerance of pneumoperitoneum, and difficulties in teaching and learning the technique.[9]

MATERIALS AND METHODS

The study was conducted at the Department of General Surgery at Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune. We used a prospective design to compare the outcomes of the extended totally extraperitoneal (eTEP) and TEP (totally extraperitoneal) surgical techniques for inguinal hernia repair. The study duration spanned from November 2022 to November 2023. Ethical approval was obtained from the Institute Ethical Committee, and patients admitted for surgeries were screened for eligibility. Those patients meeting the inclusion criteria were invited to participate, and informed written consent was obtained from each patient. Preoperative care involved conducting routine hematological tests, blood group analysis, serological tests for infectious diseases, urine examination, and electrocardiogram to assess the fitness of patients for anesthesia and surgery.

A total of 40 patients were included in the study, with 20 patients assigned to each surgical technique group. The inclusion criteria encompassed patients aged 15–65 years with uncomplicated inguinal hernias. On the other hand, patients with bilateral hernia, strangulated hernia, obstructed hernia, recurrent hernia, coagulation disorders, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease were excluded from the study. The surgical procedures, either eTEP or TEP, were performed based on patient preference. The main difference between the TEP (totally extraperitoneal) and eTEP procedures for inguinal hernia repair was in the surgical technique and access to the hernia site.

In the TEP procedure, small incisions were created in the lower abdomen, and a laparoscope and other specialized instruments were inserted. The preperitoneal space was accessed by carefully dissecting through the layers of the abdominal wall, without entering the peritoneal cavity. The hernia defect was then identified, and a mesh was placed to reinforce the weakened area, securing it in place. Throughout the procedure, the peritoneal cavity remained undisturbed. The eTEP procedure, an extension of the TEP technique, involved a similar initial step of creating small incisions in the supraumbilical region and inserting a laparoscope. However, additional working ports were placed to gain better access to the hernia site. This allowed for enhanced visualization and dissection of the preperitoneal space. Using specialized instruments, the surgeon dissected and created a larger working space, facilitating the placement of a larger mesh to cover a wider area. The eTEP procedure aimed to provide a more extensive coverage and repair of the hernia defect.

All surgeries were conducted by the same surgical team to maintain consistency. Intraoperative findings and postoperative data were recorded using a standardized form. Postoperative care was provided according to the established protocols. Data analysis was performed using statistical software, and the unpaired t-test was used to compare the outcomes between the two surgical technique groups.

RESULTS

The mean age of the 40 study participants was 44.51 years, with a standard deviation of 15.20 years. The highest age recorded was 75 years, while the lowest was 19 years. Among the participants, 29 (72.5%) were male and 11 (27.5%) were female. In terms of age distribution, 10 (25%) participants belonged to the 41–50 years age group, followed by 8 (20%) subjects in the 31–40 years age group. Out of the 40 study participants, 23 (57%) underwent right side hernia repair, while the remaining 17 (43%) underwent left side hernia repair. The mean duration of eTEP surgery was 48.70 min with a standard deviation of 7.505 min, which was significantly lower than the mean duration of TEP surgery, which was 74.20 min with a standard deviation of 7.78 min (P = 0.00). This indicates that the duration required for inguinal hernia repair surgery through eTEP was shorter compared to TEP surgery. The mean pain score following eTEP surgery was 3.75 with a standard deviation of 0.55, which was significantly lower than the mean pain score following TEP surgery, which was 5.15 with a standard deviation of 0.745 (P = 0.00). This suggests that patients undergoing eTEP surgery experienced less pain compared to those undergoing TEP surgery. Furthermore, the mean duration of hospital stay following eTEP surgery was 1.70 days with a standard deviation of 0.657 days, which was significantly lower than the mean duration of hospital stay following TEP surgery, which was 3.65 days with a standard deviation of 1.137 days (P = 0.00). This implies that patients undergoing eTEP surgery were discharged earlier than those undergoing TEP surgery.

Patients undergoing eTEP had a lower incidence of hematoma (0 cases) and surgical emphysema (0 cases) compared to TEP, which recorded three cases of hematoma and one case of surgical emphysema. However, TEP had more complications related to seroma, with four cases recorded, compared to one case for eTEP. TEP surgeries were associated with more complications following after surgery (P = 0.008). There was no recurrence of inguinal hernia after both surgeries. Regarding conversion, eTEP had zero cases requiring conversion, while TEP recorded eight cases. TEP surgeries were associated with conversion to open surgery (P = 0.002). This suggests that eTEP may be a more efficient and reliable surgery overall, as it had a lower likelihood of requiring conversion following TEP surgery, which was 3.65 days with a standard deviation of 1.137 days (P = 0.00). This implies that patients undergoing eTEP surgery were discharged earlier than those undergoing TEP surgery.

DISCUSSION

Inguinal hernia repair is a common surgical procedure that is performed worldwide, with millions of people undergoing it annually.[10] While some patients may not experience any symptoms, most require surgery within 5 years of diagnosis.[11] Although surgery is generally successful, there is still an 11% recurrence rate, and recurrences can happen even after many years. Laparoscopic techniques have been developed, which have improved the operation, but it can still be challenging to determine the best course of action for each patient due to numerous surgical methods available. Open inguinal hernia repairs can be categorized as tissue repair or mesh repair, with several named techniques for performing tissue repair. A new technique called eTEP was introduced in 2012 by Daes, which aims to effectively manage larger groin hernias by creating a larger space than traditional TEP techniques. If the hernia defect is too wide to be closed without tension, a component separation procedure may be necessary to achieve proper closure.[9]

The demographic profile of both groups was similar for those undergoing inguinal hernia repair, with a male predominance observed in each. The mean age for patients in Group eTEP was 51.10 ± 16.75 years, while patients in the TEP group had a mean age of 44.50 ± 13.68 years. In another study conducted by Singh et al., the mean age for patients in both eTEP and TEP groups was 45.7 and 44.2 years, respectively, with male dominance observed in each group.[12] Another study by Köckerling et al. concluded that there was no significant difference in mean age and BMI between the recurrent operations in TEP.[13] In our study, 23 subjects (57%) received hernia repair on their right side, while 17 subjects (43%) received repair on their left side. In Singh et al.’s study, the eTEP group had a higher number of patients with right-sided hernias, with 20 (80%) patients, compared to the TEP group, which had 19 76%) patients. On the other hand, the TEP group had more patients with left-sided hernias, with 6 (24%) patients, compared to the eTEP group, which had 5 (20%) patients.[12]

In our study, eTEP surgery had a significantly shorter mean duration (48.70 ± 7.505 min) compared to TEP surgery (74.20 ± 7.78 min; P = 0.00). Patients who had eTEP surgery also experienced lower mean pain scores (3.75 ± 0.55) compared to those who had TEP surgery (5.15 ± 0.745; P = 0.00). In addition, the mean hospital stay for eTEP surgery patients was shorter (1.70 ± 0.657 days) than for TEP surgery patients (3.65 ± 1.137 days; P = 0.00). In Singh et al.’s study, they also found that the mean operative time was shorter for the eTEP group at 127.5 ± 23.4 min compared to the TEP group at 167.6 ± 32.4 min. The mean postoperative parenteral analgesia required was also lower in the eTEP group at 12.3 ± 2.5 compared to the TEP group at 21.4 ± 5.5. However, they found that the mean hospital stay was shorter for the eTEP group at 1.1 ± 0.3 days compared to the TEP group at 1.7 ± 0.7 days. In addition, the duration to return back to work was shorter for the eTEP group at 9.9 ± 3.4 days compared to the TEP group at 11.6 ± 3.6 days.[12]

Hospital stay after TEP surgery was reported to be higher than eTEP by Joshi and Dekhaiya, while Rekhi et al. found no statistical difference in hospital stay or time to return to usual activity between TEP and TAPP.[14,15] Pain score was found to be higher in TEP than TAPP by Rekhi et al. and VAS score showed significant correlation between TEP and eTEP groups, with high scores in TEP at 12 h postsurgery.[15] Vinay and Balasubrahmanya reported low pain scores, similar to Sharma et al. who found that pain scores were less in the TAPP group.[16,17]

Our study found that eTEP for inguinal hernia repair had lower incidences of hematoma and surgical emphysema compared to TEP, while eTEP had fewer complications related to seroma. TEP surgeries were associated with more complications following surgery and a higher likelihood of requiring conversion to open surgery. However, both surgeries had no recurrence of inguinal hernia. Overall, eTEP may be a more efficient and reliable surgery. Singh et al. found that in their study, the majority of patients in Group TEP (25 patients) experienced complications such as conversion to TAPP (4 patients or 16.0%). In Group eTEP (25 patients), most patients experienced complications related to proceeding with surgery without versus needle decompression (8 patients or 32%), followed by seroma (2 patients or 8.0%).[12]

Alam and Sheen studied TEP for inguinal hernias and found that while it has a successful track record, it has a steeper learning curve and can lead to more serious complications such as vascular and bladder injuries. Early recognition is essential for managing these complications.

Conservative measures are usually sufficient for rectus sheath hematomas, while bladder injuries require immediate repair to prevent sepsis. Late presentation of bladder injuries may require more invasive intervention.[18]

CONCLUSION

Based on the study results, the eTEP technique appears to have several advantages over TEP for inguinal hernia repair, including a lower incidence of hematoma and surgical emphysema, and a lower likelihood of requiring conversion to open surgery. However eTEP had fewer complications related to seroma, and the study found a higher incidence of complications following TEP surgery. Overall, the study suggests that both eTEP and TEP techniques can be effective options for hernia repair, but the choice of technique should be based on individual patient factors and the surgeon’s experience and preference.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.