Surg Endosc (2013) 27:4702–4710 DOI 10.1007/s00464-013-3118-x
and Other Interventional Techniques
Comparison of open and laparoscopic preperitoneal repair of groin hernia Jianwen Li • Xin Wang • Xueyi Feng Yan Gu • Rui Tang
•
Received: 16 February 2013 / Accepted: 16 July 2013 / Published online: 23 August 2013 Ó Springer Science+Business Media New York 2013
Abstract Background Compared with laparoscopic groin herniorrhaphy, the open procedure used in most former studies was Lichtenstein repair. However, unlike the totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) laparoscopic techniques, Lichtenstein procedure is a premuscular but not preperitoneal repair. This retrospective study compared the outcomes between laparoscopic preperitoneal and open preperitoneal procedure— modified Kugel (MK) herniorrhaphy. Methods Groin hernia patients older than 18 years who underwent open MK or laparoscopic preperitoneal herniorrhaphy in our hospitals between January 2008 and December 2010 were enrolled. Baseline characteristics, recurrence, and intraoperative, short-term, and long-term postoperative complications were recorded. Results Among the 1,760 included patients (530 open and 1,230 laparoscopic), 96.08 % completed the follow-up (24–60 months). The patients in the open group were older than laparoscopic group (p \ 0.001). More bilateral
(91.45 %) and recurrent (82.12 %) hernia patients underwent laparoscopic procedures (p \ 0.001 and p = 0.004, respectively). The overall recurrence rate was 0.71 %, with no significant difference between the two approaches (p = 0.227). The overall complication rate was lower for the laparoscopic than the open approach (14.47 vs. 19.25 %, p = 0.012), whereas the rates of life-threatening complications were similar (1.51 vs. 0.98 %, p = 0.332). The laparoscopic group had significantly lower incidence rates of wound infection and chronic pain (p = 0.016 and p \ 0.001, respectively), shorter operative time, lower visual analogue scale scores, and faster recovery than the open group (p \ 0.001). Conclusions As preperitoneal herniorrhaphy, both MK and laparoscopic (TEP/TAPP) procedures are safe and effective, with low incidence rates of life-threatening complications and recurrence. The laparoscopic approach is superior in terms of lower incidence rates of infection and chronic pain, shorter operative time, and faster recovery; however, careful surgical procedure selection and implementation of technical details are required.
Jianwen Li and Xin Wang have contributed equally to this work.
Keywords Groin hernia Preperitoneal repair Laparoscopic repair Totally extraperitoneal (TEP) Transabdominal preperitoneal (TAPP) Open modified Kugel repair
J. Li Department of General Surgery, Hernia and Abdominal Wall Surgery Center of Shanghai Jiaotong University, Ruijin Hospital, Affiliated to Shanghai Jiaotong University, School of Medicine, Shanghai, China X. Wang X. Feng Y. Gu R. Tang (&) Department of General Surgery, Hernia and Abdominal Wall Surgery Center of Shanghai Jiaotong University, Shanghai Ninth People’s Hospital, Affiliated to Shanghai Jiaotong University, School of Medicine, No. 639, Zhizaoju Road, Shanghai, China e-mail:
[email protected] X. Wang e-mail:
[email protected]
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Groin hernia repair is one of the most common surgical procedures. During the past 30 years, tension-free repair using a prosthetic mesh became the mainstay of herniorrhaphy. Besides open tension-free procedures, laparoscopic techniques also were introduced to hernia surgery, of which the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) procedures are the most successful
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and frequently used. TAPP and TEP were first introduced 20 years ago [1–3]. Adhering to the principles established by Stoppa [4, 5] for open posterior repairs, both preperitoneal laparoscopic procedures involve dissection of the entire posterior floor of the groin and placement of a mesh in the preperitoneal space to repair all three potential sites of herniation, resulting in their success and acceptance. Although laparoscopic hernia repair has proved to be superior to open repair, because it has been associated with short-term convalescence [6] and less pain [7], the open anterior approach is still the most frequently used technique by general surgeons. Many randomized, controlled trials have been conducted to compare open and laparoscopic procedures in several aspects, such as recurrence [8, 9], complications [9–11], chronic pain [12], quality of life [7, 10], and even cost-effectiveness [13]. However, a consensus has not been reached as to which approach is better. However, Lichtenstein herniorrhaphy, the open procedure used in most trials, applies a mesh on the premuscular layer and not in the preperitoneal space, unlike the TEP or TAPP laparoscopic technique. This difference in mesh location must have caused some discrepancies in the comparison of the two approaches, obtaining results that may not distinguish the exact disparity between both. Therefore, it would be more appropriate to compare two techniques of preperitoneal repair that use either the open and laparoscopic approach; however, very few studies with a small sample size have conducted such a comparison [14–16]. Transinguinal preperitoneal (TIPP) repair using the modified Kugel (MK) patch is a classic open anterior preperitoneal technique for tension-free herniorrhaphy. The layer where the mesh is placed, the dissection area in preperitoneal space, and the regions covered by the mesh in the MK procedure are completely identical with those in the TEP and TAPP laparoscopic techniques. The only distinction is their respective approach: i.e., open versus laparoscopic. Therefore, we conducted this retrospective study to compare the outcomes in the open MK and laparoscopic TEP/TAPP procedures.
Materials and methods Patients Groin hernia patients older than age 18 years who underwent open MK or laparoscopic preperitoneal herniorrhaphy between January 2008 and December 2010 in Ward I and Ward II of General Surgery of Shanghai Ninth People’s Hospital and Ward VI of General Surgery of Shanghai Ruijin Hospital were included in this retrospective study. The section of hernia and abdominal wall of both hospitals
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is under the administration of the Hernia and Abdominal Wall Surgery Center of Shanghai Jiaotong University. The exclusion criteria were as follows: patients whose physical statuses were graded as the American Society of Anesthesiologists (ASA) class VI or V, patients with incarcerated hernia who received an emergency operation, and patients who underwent another concomitant procedure. The demographic characteristics and ASA classification grades of the patients are shown in Table 1. All patients underwent standardized repairs performed by qualified surgeons who previously performed at least 25 open or laparoscopic repairs [17, 18]. The open procedures were performed under local/epidural/spinal/general anesthesia, and all the laparoscopic procedures were performed under general anesthesia. The patients received 2 g of cephradine or 0.6 g of clindamycin phosphate (in cases of allergy to cephradine) 30 min before the operation and another dose of the same antibiotic after the operation. Surgical techniques Open procedure The open MK procedure was performed as previously described [19], using a large oval MK hernia patch (a monofilament knitted polypropylene mesh 13.0 9 9.5 or 12.0 9 8.0 cm in size, which comprised a double layer containing a pocket, strap, and memory recoil ring; Bard). After closure of the external oblique and Scarpa’s fascia with a running 3-0 Vicryl Plus suture (polyglactin; Ethicon), the skin incision was closed with a running subcuticular stitch. Laparoscopic procedure The TAPP and TEP procedures were performed as previously described by Felix [20]. In the TEP operation, because we did not have balloon dissector and Hasson self-sealing trocar, after entering the space in front of the posterior rectus sheath, we inserted a 10- or 12-mm trocar and dissected the central preperitoneal space from the umbilicus down to the pubis just with the aid of the telescope. After completing the dissection, we applied a large 3D-Max mesh (16.0 9 10.8 cm; Bard) or Prolene, Vypro, or Ultrapro mesh (15 9 10 cm; Ethicon) to cover the whole myopectineal orifice, with or without tacker fixation (Auto Suture Protack, Tyco). In the TAPP procedure, the open peritoneum was sealed using an Endoscopic Multifeed Stapler (Ethicon) or a running 2-0 or 3-0 Vicryl suture. Finally, the 10- or 12-mm port fascia was closed using a 2-0 Vicryl suture (Ethicon), and then the port sites were closed with running subcuticular stitch or skin glue.
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Table 1 Baseline characteristics of the patients in the two groups Open (530 cases) n Age (year)
67.33 ± 13.24
Male:female
493:37
Laparoscopic (1,230 cases) %
n
Statistics
p
3.972
0#
94.47:5.53
1.393
0.238
81.172
0#
%
64.36 ± 14.9 93.02:6.98
1,162:68
Hernia Repairs (sides)
556
Bilateral
26
4.91
278
1,508 22.6
Unilateral
504
95.09
952
77.4
Right (unilateral) Left (unilateral)
311 193
61.71 38.29
564 388
59.24 40.76
0.833
0.361
Primary (sides)
524
94.24
1,361
90.25
8.176
0.004#
Recurrent (sides)
32
5.76
147
9.75 5.359
0.252a
4.158
0.125
Nyhus classification (sides) I
93
16.73
234
15.52
II
110
19.78
333
22.08
IIIA
91
16.37
264
17.5
IIIB
224
40.29
519
34.42
IIIC
6
1.08
11
0.73
IV
32
5.75
147
9.75
I
240
45.28
622
50.57
II
192
36.23
400
32.52
III
98
18.49
208
16.91
Lost to follow-up Deceased
18 6
3.40 1.132
34 11
2.76 0.833
0.516 0.219
0.473 0.634
Completion
506
95.47
1,185
96.34
0.744
0.388
ASA classification
* p \ 0.05 #
p \ 0.01
a
Recurrent hernias were excluded when comparing the Nyhus classification between the two groups because they were indications for laparoscopic procedure
Data collection
Statistical analysis
The type of anesthesia, hernia characteristics (including the type of hernia according to the Nyhus classification [21]), operation duration (skin to skin), visual analogue scale (VAS) score (0–10 cm) at 24 h after operation, length of postoperative hospital stay, number of patients who returned to unrestricted movement at 2 postoperative weeks, intraoperative complications, short-term (within 1 month) and long-term postoperative complications, and recurrence were recorded. Two independent observers examined each patient at 2, 4 weeks, 3 months, and 1 year after surgery for the presence of complications, complaints, or recurrence. Thereafter, telephone interviews were conducted yearly, and the patients with complaints visited the clinic for physical examination for possible recurrence. Chronic pain was defined as sustained pain or discomfort that lasts longer than 3 months [22].
Continuous data were presented as mean ± SD and compared using the Student t test (two-tailed). Frequencies were compared using the Pearson v2 test and Fisher exact test. Data analysis was performed using SPSS version 13.0. A p \ 0.05 was considered statistically significant.
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Results Between January 2008 and December 2010, a total of 1,760 patients with 2,064 hernial sides were enrolled in the study, of whom 530 underwent an open MK procedure and 1,230 underwent a laparoscopic preperitoneal procedure (451 TAPP and 779 TEP procedures). Shanghai Ninth People’s Hospital contributed 229 cases of open and 510 laparoscopic surgeries and Shanghai RuiJin Hospital
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contributed 291 open and 730 laparoscopic surgeries (p = 0.259). Table 1 presents the baseline characteristics of the patients according to treatment group. The patients in the open group were comparably older than those in the laparoscopic group. More bilateral (91.45 %) and recurrent (82.12 %) hernia patients underwent laparoscopic herniorrhaphy. Other demographic characteristics, such as gender, Nyhus classification, ASA classification, and follow-up, were similar between the two groups. All of the patients returned to the clinic 1 month after the operation, so intraoperative and short-term complications were recorded for all patients. The data collection was closed in December 2012. During the 24–60 months follow-up period, 52 patients were lost to follow-up and 17 patients died from other diseases; the remaining 1,691 patients (96.08 %) completed the entire duration of the follow-up. Conversion was required for four patients in the laparoscopic group: three TEP cases were converted to the TAPP technique due to a technical problem (inability to complete the procedure successfully), and one TAPP case was converted to the open procedure due to bladder injury. As shown in Table 2, the operative time and length of postoperative stay in the laparoscopic group were shorter than those in the open group (33.84 ± 20.75 vs. 67.52 ± 39.25 min and 1.83 ± 1.59 vs. 4.03 ± 2.49 days, respectively; p \ 0.001). In addition, the laparoscopic group had lower VAS scores and more patients in the laparoscopic group returned to unrestricted movement at 2 postoperative weeks. The overall complication rate of the laparoscopic group was lower than that of the open group (13.98 vs. 18.11 %; p = 0.027). The two groups had similar intraoperative and short-term postoperative complication rates; however, the open group had higher long-term postoperative rates (Tables 3, 4). Furthermore, we assessed the incidence of
life-threatening complications, including intestine injury, bladder injury, cardiac and pulmonary disorders, and ileus. The incidence rates were similarly low for both approaches (open vs. laparoscopic, 1.51 vs. 0.98 %; p = 0.332). The most common intraoperative complication was injury of the inferior epigastric vessel, with three cases in the open group and seven in the laparoscopic group, which were treated by ligation or clamping of the artery. One small intestine injury occurred in a patient of recurrent hernia during the TEP procedure when transecting the sac containing adhesive intestine. However, we did not find the injury in the surgery, and the patient underwent laparotomy for acute peritonitis the next day. The perforation was closed and the mesh was removed. The patient recovered uneventfully after the second surgery and underwent a Lichtenstein repair 6 months later. Bladder injuries occurred in one patient in the open and laparoscopic groups, respectively. Both patients had big direct hernias. The injuries were repaired with sutures, requiring the use of an indwelling catheter for 2 weeks; however, the patient who underwent a laparoscopic repair had to convert to open Lichtenstein repair. Postoperative seroma was the most common short-term complication, and most developed in the patients with an undissected large sac, all of whom were treated conservatively. There was no significant difference between the two groups in terms of the incidence of postoperative seroma. One 93-year-old patient in the open group died of pneumonia 5 days postoperatively. No surgery-related death was encountered in the laparoscopic group. One case of mechanical ileus occurred due to intestinal adhesion with the mesh, because the peritoneum was not completely sealed during the TAPP procedure. The patient underwent laparotomy 3 months after the hernia surgery, in which the adhesion was dissected and the adhesive intestine was cut while preserving the mesh. After undergoing a TAPP procedure, two patients developed enteroparalysis and
Table 2 Comparison of the operative times, recovery durations, and VAS scores Open (n = 530)
Laparoscopic (n = 1,230)
Statistics
p
Total
67.52 ± 39.25
33.84 ± 20.75
19.029
0#
Bilateral
135.38 ± 52.43
48.52 ± 22.93
8.374
0#
Unilateral
64.02 ± 35.12
29.57 ± 17.96
20.64
0#
Postoperative hospital stay (days)
4.03 ± 2.49
1.83 ± 1.59
35.767
0#
VAS
2.37 ± 1.1
2.21 ± 0.98
Returned to unrestricted movement, n (%)
513 (96.79)
1,219 (99.11)
Operative time (min)
2.7267 12.66
0.006# 0#
Data are expressed as mean ± SD, unless otherwise specified * p \ 0.05 #
p \ 0.01
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Table 3 Comparison of the intraoperative and short-term postoperative complications Open (n = 530) n Intraoperative
Laparoscopic (n = 1,230) %
n
Statistics
p
%
4
0.75
9
0.73
0
1
Vessel
3
0.57
7
0.57
0
1
Intestine
0
0
1
0.08
Fisher
1
Bladder
1
0.19
1
0.08
Fisher
0.512
Anesthetic related
0
0
0
0
Fisher
1
55
10
Short-term postoperative
106
8.62
0.861
0.353
Seroma Hematoma
26 2
4.91 0.38
75 3
6.1 0.24
0.973 0
0.324 1
Anesthesia related
8
1.51
9
7.31
2.342
0.126
Wound infection
5
0.94
1
0.08
5.764
0.016*
Orchitis
2
0.38
1
0.08
Fisher
0.217
Ileus
0
0
3
0.24
Fisher
0.558
Cardiac
3
0.57
6
0.49
0
1
Pulmonary
4
0.75
3
0.24
1.321
0.251
Digestive tract
2
0.38
0
0
Fisher
0.091
Others
3
0.57
5
0.41
0.005
0.944
10.75
115
9.35
0.829
0.362
Overalla (event)
59
Overallb (n)
57
115
A patient may have more than one complication * p \ 0.05 #
p \ 0.01
a
Number of events of all the intraoperative and early postoperative complications
b
Number of patients with complications
Table 4 Comparison of the long-term postoperative complications Open (n = 506)
Laparoscopic (n = 1,185)
p
n
%
Recurrence Testis atrophy
6 1
1.19 0.2
6 1
0.51 0.08
1.459 Fisher
0.227 0.509
Chronic pain
37
7.31
16
1.35
41.516
0#
Mesh-related infection
2
0.4
0
0
Fisher
0.089
Port-site hernia
NA
0
0
NA
NA
Overalla
46
9.09
23
1.94
46.315
0#
b
40
7.91
17
1.43
45.579
0#
Overall
n
Statistics
%
* p \ 0.05 #
p \ 0.01
a
Includes recurrent cases
b
Does not include recurrent cases
were treated conservatively. A significant difference in the incidence of postoperative wound infection was observed between the two groups. Five patients in the open group had wound infection and one in the laparoscopic group had wound infection in the 12-mm trocar site; however, all of
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the infections were superficial and were treated effectively with a dressing. At the closure of data collection, 1,691 patients (96.08 %) completed the follow-up. The overall recurrence rate in our study was 0.71 % (n = 12): 1.19 % (n = 6) in
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the open group and 0.51 % (n = 6) in the laparoscopic group (p = 0.227). All recurrences occurred at 3–35 months (median, 11 m) after surgery, and only two recurrences in the open group occurred later than 2 years after surgery. The overall long-term postoperative complication rate in the open group was higher than that in the laparoscopic group (7.31 vs. 1.35 %, p \ 0.001). Among all the longterm complications, chronic pain contributed to the difference between the two groups. In addition, two cases of mesh-related infection were found in the open group at 8 and 29 months. In one case, the mesh was removed, and in the other, the patient was transferred to another hospital. In contrast, no mesh-related infection and trocar-site hernia were encountered in the laparoscopic group.
Discussion Tension-free repair using a prosthetic mesh is the primary surgical method for treating groin hernia. There are many procedures for tension-free herniorrhaphy with different mesh locations. In addition to placing the mesh premuscular sublay to the external oblique, placing it in the preperitoneal space is another important choice [23, 24]. The mesh is sandwiched between the peritoneum and the transversalis fascia, and secured over the myopectineal orifice using intra-abdominal pressure. The preperitoneal mesh reinforces the whole myopectineal orifice, including anatomical structures, such as the Hesselbach triangle, internal inguinal ring, and annulus femoralis, where the groin hernia sac originates. Therefore, theoretically, preperitoneal repair can treat the three most common types of groin hernia: indirect, direct, and femoral hernias. It has been associated with low recurrence rates and prevents postoperative occurrence of any of the three types of hernia, especially femoral hernia, which cannot be achieved by premuscular and inlay repair procedures, such as the Lichtenstein and Rutkow techniques. The preperitoneal space can be accessed through various approaches, including open and laparoscopic procedures. The TEP and TAPP laparoscopic techniques are widely accepted and used for preperitoneal repair. The early introduced open preperitoneal tension-free repair, the Stoppa–Wantz technique [5], is now less frequently used, because it involves complicated procedures and is associated with major injuries [25]. In 1999, Kugel described an open posterior preperitoneal groin herniorrhaphy using a small suprainguinal incision, with a low recurrence rate of 0.62 % [26]. However, in the Kugel repair, the placement of the polypropylene mesh in the preperitoneal space is through a posterior approach, which is quite different from the
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conventional anterior hernia repair methods. Surgeons should have a proper understanding of the regional anatomy and its relation to the patch and have to undergo a long period of learning curve to become familiar with Kugel technique, during which high complication and recurrence rates are to be expected [27–29]. Later, the modification based on Kugel was developed, changing the approach from posterior to anterior, which is the open approach most familiar to surgeons [19, 30–32]. This open anterior preperitoneal repair procedure also is termed ‘‘transinguinal preperitoneal repair (TIPP)’’ [32]. In the MK procedure, the mesh type and location are the same as those in the Kugel method. Unlike the original Kugel procedure, the MK technique was demonstrated to have excellent results even during the initial experience [19, 33]. In Li’s 2 years of experience, the anterior approach for the MK repair was found to be advantageous in that it requires a shorter learning curve and has little technical difficulty. Moreover, it is a safe and minimally invasive procedure, with low recurrence and complication rates, as well as financial costs [19]. In Western countries, the Lichtenstein technique is the most predominant open procedure and often is used as the criterion standard when comparing other procedures. In contrast, in China, which has the largest population in the world, the Rutkow and MK procedures are more commonly used instead of the Lichtenstein procedure in surgical practice, possibly because many Chinese patients do not present for surgery in the early stage and hence have larger hernias during their initial presentation. In the past 5 years, the most frequently used open procedure in our center is the MK procedure, which made it possible for us to compare between the open and laparoscopic approaches for preperitoneal herniorrhaphy. Our study demonstrated that the open and laparoscopic approaches are both effective and safe for preperitoneal herniorrhaphy, based on the low rates of recurrence and life-threatening complications. Some former studies comparing open Lichtenstein and laparoscopic procedures obtained varied recurrence rates [34, 35]. Therefore, recurrence rate was our primary objective in our comparison of the open and laparoscopic preperitoneal procedures. Our results indicated relatively low and similar recurrence rates in both approaches (1.19 vs. 0.51 %, p = 0.227), which we speculated to have resulted from the above-mentioned advantages of preperitoneal repair. An anatomical study reported the mean dimensions of the myopectineal orifice to be 7.8 cm in width and 6.5 cm in height [36]. However, the smallest mesh that we used in our open MK procedures measured 12 9 8 cm and the biggest mesh (3D-Max) that we used in our laparoscopic procedures measured 16 9 10 cm, both larger than the dimension of the normal myopectineal
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orifice. Therefore, adequate dissection of the preperitoneal space, a mesh large enough for adequate overlapping, and flattening of the mesh to cover the whole myopectineal orifice lead to a successful preperitoneal repair, and minimize and may even avoid recurrence. When analyzing our recurrent cases, in 7 of 12 cases reoperated in our hospitals, the recurrence was due to technical factors. Four cases of recurrence were caused by a missed defect in the open group. One case of recurrence was caused by folding of the mesh in open group. One case was caused by inadequate overlapping; and another, by improper fixation in laparoscopic group. In our study, the recurrence rate after the open MK procedure was slightly higher than that after the laparoscopic procedure, although the difference was not significant. Currently, if the patient is suitable to undergo either approach, the surgeons in our center prefer the laparoscopic procedure over the open approach because the former not only allows a larger mesh to provide more overlap but also allows operation under direct view as opposed to under partial view in the latter. Procedural safety is as important as recurrence prevention in groin herniorrhaphy. Therefore, the second objective of our study was to compare the two methods in terms of safety based on the occurrence of other complications, especially those that are life-threatening. Some early reports indicated that intraoperative and short-term postoperative complications were more frequent in the laparoscopic repair group than in the open repair group [35, 37, 38]; however, some recent reports obtained similar results for the two approaches [39]. In our study, the overall complication rate was lower in the laparoscopic approach than in the open approach, but the rate of life-threatening complications was similarly low for both approaches. Concerns have been raised for life-threatening complications related to laparoscopic manipulation, especially intestine injury, which rarely occur in open procedures. In our study, high transection of the recurrent hernia sac that was intensively adhered to the intestine inevitably inflicted bowel injuries during one TEP procedure. A case of mechanical ileus due to intestinal adhesion with the mesh resulted from the peritoneum not being completely sealed during the TAPP procedure. These complications indicate that the choice of the appropriate procedure should be individualized for each patient. For example, in cases of recurrent or irreducible groin hernia, the TAPP technique is preferred, because it displays better anatomical structures, making it easier to avoid possible complications. In addition, any technical detail should be implemented during the laparoscopic procedure. In our comparison of postoperative complications between the laparoscopic and MK procedures, we found that the laparoscopic procedure resulted in less postoperative pain and lower incidence rates of wound infection.
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In our study, the VAS scores and incidence rates of chronic pain after the open MK repair were higher than those after the laparoscopic procedure. This finding concurs with those from a meta-analysis and other clinical trials that demonstrated the laparoscopic technique to cause less pain than the open technique [10, 12, 40–42]. Several causes for the development of postoperative pain after groin hernia repair have been suggested [40]. When comparing open and laparoscopic procedures, Ko¨ninger et al. [42] concluded that the incidence of postoperative pain differed according to the type of surgical approach, but the presence of a prosthetic mesh was not the source of long-term chronic pain. We agree with the author that surgical trauma to the groin plays a crucial role. Groin dissection using an open anterior approach causes more trauma than the laparoscopic approach. Open techniques are associated with possible injury to peripheral nerve structures and scarring of the abdominal wall [43], whereas laparoscopic techniques minimize such risks [44]. Nerve injury during laparoscopic hernia repair, especially to the nervus cutaneus femoris lateralis, has been reported, especially at the beginning of the laparoscopic repair era; however, this seems to be avoidable with the correct operating technique [45]. The infection rate was higher after the open MK procedure. Five patients (0.94 %) in the MK group had wound infection, whereas only one patient (0.08 %) in the laparoscopic group had a wound infection in the umbilical trocar site. Two cases of late mesh-related infections occurred in the MK group, whereas no mesh-related infection occurred in the laparoscopic group. Our results were easy to interpret and were consistent with those from the meta-analysis comparing the Lichtenstein and laparoscopic techniques [46]. The guidelines published by the European Hernia Society also regarded it as conclusive based on level 1A evidence [47]. According to our findings, besides less pain and a lower incidence of wound infection, other significant advantages of the laparoscopic procedures over the open MK repair include earlier recovery, shorter postoperative hospital stay, and shorter operation time. The first two advantages concurred with those reported in other studies comparing the open and laparoscopic procedures [40], but the last one is paradoxical for two possible reasons: (1) performing an MK repair may be a little more difficult than performing a Lichtenstein repair, involving careful dissection of the preperitoneal space and inserting the mesh deeper into the space, which require more time, and (2) we have experienced laparoscopic surgeons. The two participant units were both university hospitals, which perform more than 600 groin herniorrhaphies per year and have practiced laparoscopic techniques for more than 5 years. All our surgeons had previously performed more than 25 laparoscopic operations and had overcome their learning curves
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including one surgeon who had performed more than 500 operations. In addition, more TEP procedures were performed than TAPP procedures (63.33 vs. 36.67 %), which need longer operation time to open and close the peritoneum. The major merit of our study is its large sample size and relatively long-term follow-up period. Its major limitation was that it’s still a retrospective controlled study without advanced design. Some of the baseline characteristics of the two groups differed, because both the surgeons and patients participated in making the decision with regard to which operation method to use. More bilateral and recurrent hernia patients underwent laparoscopic repair, which are the main indications of laparoscopic technique. In university hospitals in a metropolis, patients and surgeons tend to choose minimally invasive techniques. However, this is not the case for most areas of China. As a developing country with the largest population, open surgery is still the mainstay for hernia repair owing to its cost-effectiveness. Furthermore, the medical insurance coverage varies in the diverse populations of Shanghai, and the cost of the laparoscopic instrument and general anesthesia are much higher than that of open surgery. Therefore, the patient who is cost-sensitive will choose open surgery, although he or she is suitable to undergo a laparoscopic procedure. In addition, the patients in the open group in this study were older than those in the laparoscopic group. Both the surgeons and older patients have a scruple because of the increasing risk associated with the use of general anesthesia compared with local anesthesia. Therefore, we cannot exclude that the discrepancy in the complication rates between the two approaches did not partially come from the selection of the surgical approach. A prospective, randomized, controlled study comparing open and laparoscopic preperitoneal repair is now ongoing, and we hope that it will give us more concrete conclusions.
Conclusions According to this retrospective study, as methods of preperitoneal hernia repair, both open MK and laparoscopic herniorrhaphy (TEP/TAPP) have the advantage of being safe, with low incidence of recurrence. However, the laparoscopic approach is superior to the open MK technique in terms of lower incidence rates of chronic pain and wound infection, shorter operative time, and faster recovery. However, careful attention should be given to the selection of the appropriate surgical procedure and implementation of technical details to avoid life-threatening complications related to laparoscopic manipulation. Moreover, prospective, randomized, controlled trials are needed to uncover further evidence that supports our findings.
4709 Acknowledgments The authors thank Jun Ma and Huichun Wang for their contribution to this paper in data collection and follow-up. Disclosures Jianwen Li, Xin Wang, Xueyi Feng, Yan Gu, and Rui Tang have no conflicts of interest or financial ties to disclose.
References 1. Felix EL, Michas C (1993) Double-buttress laparoscopic herniorrhaphy. J Laparoendosc Surg 3:1–8 2. Voeller GR, Mangiante EC, Britt LG (1993) Preliminary evaluation of laparoscopic herniorrhaphy. Surg Laparosc Endosc 3:100–105 3. McKernan JB, Laws HL (1993) Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 7:26–28 4. Stoppa RE (1989) The treatment of complicated groin and incisional hernias. World J Surg 13:545–554 5. Wantz GE (1989) Giant prosthetic reinforcement of the visceral sac. Surg Gynecol Obstet 169:408–417 6. Collaboration EH (2000) Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 87:860–867 7. Gong K, Zhang N, Lu Y, Zhu B, Zhang Z, Du D, Zhao X, Jiang H (2011) Comparison of the open tension-free mesh-plug, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) laparoscopic techniques for primary unilateral inguinal hernia repair: a prospective randomized controlled trial. Surg Endosc 25:234–239 8. Eklund AS, Montgomery AK, Rasmussen IC, Sandbue RP, Bergkvist LA, Rudberg CR (2009) Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair: a randomized, multicenter trial with 5-year follow-up. Ann Surg 249:33–38 9. Pokorny H, Klingler A, Schmid T, Fortelny R, Hollinsky C, Kawji R, Steiner E, Pernthaler H, Fugger R, Scheyer M (2008) Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial. Hernia 12:385–389 10. Singh AN, Bansal VK, Misra MC, Kumar S, Rajeshwari S, Kumar A, Sagar R (2012) Testicular functions, chronic groin pain, and quality of life after laparoscopic and open mesh repair of inguinal hernia: a prospective randomized controlled trial. Surg Endosc 26:1304–1317 11. Swadia ND (2011) Laparoscopic totally extra-peritoneal inguinal hernia repair: 9 years experience. Hernia 15:273–279 12. Eklund A, Montgomery A, Bergkvist L, Rudberg C (2010) Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair. Br J Surg 97:600–608 13. Eklund A, Carlsson P, Rosenblad A, Montgomery A, Bergkvist L, Rudberg C (2010) Long-term cost-minimization analysis comparing laparoscopic with open (Lichtenstein) inguinal hernia repair. Br J Surg 97:765–771 14. Aitola P, Airo I, Matikainen M (1998) Laparoscopic versus open preperitoneal inguinal hernia repair: a prospective randomised trial. Ann Chir Gynaecol 87:22–25 15. Beets GL, Dirksen CD, Go PM, Geisler FE, Baeten CG, Kootstra G (1999) Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia? A randomized controlled trial. Surg Endosc 13:323–327 16. Bostanci BE, Tetik C, Ozer S, Ozden A (1998) Posterior approaches in groin hernia repair with prosthesis: open or closed. Acta Chir Belg 98:241–244
123
4710 17. Wright D, O’Dwyer PJ (1998) The learning curve for laparoscopic hernia repair. Semin Laparosc Surg 5:227–232 18. Liem MS, van Steensel CJ, Boelhouwer RU, Weidema WF, Clevers GJ, Meijer WS, Vente JP, de Vries LS, van Vroonhoven TJ (1996) The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair. Am J Surg 171:281–285 19. Li J, Zhang Y, Hu H, Tang W (2008) Preperitoneal groin hernia repair with Kugel patch through an anterior approach. ANZ J Surg 78:899–902 20. Felix EL, Michas CA, Gonzalez MH Jr (1995) Laparoscopic hernioplasty. TAPP vs TEP. Surg Endosc 9:984–989 21. Nyhus LM (1993) Individualization of hernia repair: a new era. Surgery 114:1–2 22. Merskey HBN (1994) Classification of chronic pain, descriptors of chronic pain syndromes and definitions of pain terms, 2nd edn. IASP, Seattle 23. Muldoon RL, Marchant K, Johnson DD, Yoder GG, Read RC, Hauer-Jensen M (2004) Lichtenstein vs anterior preperitoneal prosthetic mesh placement in open inguinal hernia repair: a prospective, randomized trial. Hernia 8:98–103 24. Read RC, Barone GW, Hauer-Jensen M, Yoder G (1993) Properitoneal prosthetic placement through the groin. The anterior (Mahorner–Goss, Rives–Stoppa) approach. Surg Clin N Am 73:545–555 25. Matthews RD, Neumayer L (2008) Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg 45:261–312 26. Kugel RD (1999) Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless, inguinal herniorrhaphy. Am J Surg 178:298–302 27. Schroder DM, Lloyd LR, Boccaccio JE, Wesen CA (2004) Inguinal hernia recurrence following preperitoneal Kugel patch repair. Am Surg 70:132–136 28. Van Nieuwenhove Y, Vansteenkiste F, Vierendeels T, Coenye K (2007) Open, preperitoneal hernia repair with the Kugel patch: a prospective, multicentre study of 450 repairs. Hernia 11:9–13 29. Dogru O, Girgin M, Bulbuller N, Cetinkaya Z, Aygen E, Camci C (2006) Comparison of Kugel and Lichtenstein operations for inguinal hernia repair: results of a prospective randomized study. World J Surg 30:346–350 30. Williams GL, McKain ES, Stephenson BM, Pelissier EP (2006) Inguinal hernia: preperitoneal placement of a memory-ring patch by anterior approach. Preliminary experience. Hernia 10:248–252 31. Pelissier EP, Blum D, Marre P, Damas JM (2001) Inguinal hernia: a patch covering only the myopectineal orifice is effective. Hernia 5:84–87 32. Pelissier EP, Ngo P, Gayet B (2011) Transinguinal preperitoneal patch (TIPP) under local anesthesia with sedation. Am Surg 77:1681–1684 33. Li J, Zhang Y, Hu H, Tang W (2008) Early experience of performing a modified Kugel hernia repair with local anesthesia. Surg Today 38:603–608
123
Surg Endosc (2013) 27:4702–4710 34. Heikkinen T, Bringman S, Ohtonen P, Kunelius P, Haukipuro K, Hulkko A (2004) Five-year outcome of laparoscopic and Lichtenstein hernioplasties. Surg Endosc 18:518–522 35. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, Henderson W (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350:1819–1827 36. Wolloscheck T, Konerding MA (2009) Dimensions of the myopectineal orifice: a human cadaver study. Hernia 13:639–642 37. Group TMLGHT (1999) Laparoscopic versus open repair of groin hernia: a randomised comparison. The MRC Laparoscopic Groin Hernia Trial Group. Lancet 354:185–190 38. McCormack K, Scott NW, Go PM, Ross S, Grant AM (2003) Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev CD001785 39. Eklund A, Rudberg C, Smedberg S, Enander LK, Leijonmarck CE, Osterberg J, Montgomery A (2006) Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair. Br J Surg 93:1060–1068 40. Collaboration EHT (2002) Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 235:322–332 41. Douek M, Smith G, Oshowo A, Stoker DL, Wellwood JM (2003) Prospective randomised controlled trial of laparoscopic versus open inguinal hernia mesh repair: five year follow up. BMJ 326:1012–1013 42. Ko¨ninger J, Redecke J, Butters M (2004) Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP. Langenbecks Arch Surg 389:361–365 43. Bower S, Moore BB, Weiss SM (1996) Neuralgia after inguinal hernia repair. Am Surg 62:664–667 44. Kumar S, Wilson RG, Nixon SJ, Macintyre IM (2002) Chronic pain after laparoscopic and open mesh repair of groin hernia. Br J Surg 89:1476–1479 45. Leibl BJ, Kraft B, Redecke JD, Schmedt CG, Ulrich M, Kraft K, Bittner R (2002) Are postoperative complaints and complications influenced by different techniques in fashioning and fixing the mesh in transperitoneal laparoscopic hernioplasty? Results of a prospective randomized trial. World J Surg 26:1481–1484 46. Schmedt CG, Sauerland S, Bittner R (2005) Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc 19:188–199 47. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13:343–403
