TAPP or TEP for Recurrent Inguinal Hernia? Population-Based Analysis of Prospective Data on 1309 Patients Undergoing Endoscopic Repair for Recurrent Inguinal Hernia

Background

Whether total extraperitoneal inguinal hernia repair (TEP) is associated with worse outcomes compared to transabdominal preperitoneal inguinal hernia repair (TAPP) for the treatment of recurrent inguinal hernia continues to be a matter of debate. The objective of this large cohort study is to compare complications, conversion rates and postoperative length of hospital stay between patients undergoing TEP or TAPP for unilateral recurrent inguinal hernia repair.

Method

Based on prospective data of the Swiss Association of Laparoscopic and Thoracoscopic Surgery, all patients who underwent elective TEP or TAPP for unilateral recurrent inguinal hernia between 1995 and 2006 were included. The following outcomes were compared: conversion rates, intraoperative complications, surgical postoperative complications and duration of operation.

Results

Data on 1309 patients undergoing TEP (n = 1022) and TAPP (n = 287) for recurrent inguinal hernia were prospectively collected. Average age, BMI and ASA score were similar in both groups. Patients undergoing TEP had a significantly increased rate of intraoperative complications (TEP 6.3 % vs. TAPP 2.8 %, p = 0.0225). Duration of operation was longer for patients undergoing TEP (TEP 80.3 vs. TAPP 73.0 min, p < 0.0023) while postoperative length of hospital stay was longer for patients undergoing TAPP (TEP 2.6 vs. TAPP 3.1 day, p = 0.0145). Surgical postoperative complications (TEP 3.52 % vs. TAPP 2.09 %, p = 0.2239), general postoperative complications (TEP 1.47 % vs. TAPP 0.7 %, p = 0.3081) and conversion rates (TEP 2.15 % vs. TAPP 1.39 %, p = 0.4155) were not significantly different.

Conclusion

This study is the first population-based analysis comparing outcomes of patients with recurrent inguinal hernia undergoing TEP versus TAPP in a prospective cohort of over 1300 patients. Intraoperative complications were significantly higher in patients undergoing TEP. The TEP technique was associated with longer operating times, but a shorter postoperative length of hospital stay. Nonetheless, the absolute outcome differences are small and thus, on a population-based level, both techniques appear to be safe and effective for patients undergoing endoscopic repair for unilateral recurrent inguinal hernia.

     

Has Shouldice Repair in a Selected Group of Patients with Inguinal Hernia Comparable Results to Lichtenstein,TEP and TAPP Techniques?

Background

In the new international guidelines only the mesh-based Lichtenstein, TEP and TAPP techniques are recommended. This present analysis of data from the Herniamed Registry compares the outcome for Shouldice versus Lichtenstein, TEP and TAPP.

Methods

Propensity score matching analyses were performed to obtain homogeneous comparison groups for Shouldice versus Lichtenstein (n = 2115/2608; 81.1%), Shouldice versus TEP (n = 2225/2608; 85.3%) and Shouldice versus TAPP (2400/2608; 92.0%).

Results

The most important characteristics of the Shouldice patient collective were younger patients with a mean age of 40 years, a large proportion of women of 30%, a mean BMI value of 24 and a proportion of defect sizes up to 3 cm of over 85%. For this selected patient collective, propensity score matched-pair analysis did not identify any difference in the perioperative and one-year follow-up outcome compared with TAPP, fewer intraoperative (0.5 vs. 1.3%; p = 0.009) but somewhat more postoperative complications (2.3 vs. 1.5%; p = 0.050) compared with TEP and advantages with regard to pain at rest (4.6 vs. 6.1%; p = 0.039) and on exertion (10.0 vs. 13.4%; p < 0.001) compared with the Lichtenstein technique.

Conclusion

For a selected group of patients the Shouldice technique can be used for primary unilateral inguinal hernia repair while achieving an outcome comparable to that of Lichtenstein, TEP and TAPP operations.

     

Inguinal Hernia Repair: Local or General Anaesthesia?

INTRODUCTION

Specialist hernia centres and public hospitals with a dedicated hernia service (Plymouth Hernia Service) have achieved remarkable results for inguinal hernia repair with the use of local anaesthesia and set the standards for groin hernia surgery. There is minimal data in the literature as to whether such results are reproducible in the National Health Service in the UK.

PATIENTS AND METHODS

A retrospective analysis of all inguinal hernia repairs performed in one district general hospital over a 9-year period was performed. The outcome measures were type of anaesthesia used, early and late postoperative complications and recurrence. A postal questionnaire survey was conducted to obtain satisfaction rates. In addition, a postal questionnaire survey of consultant surgeons in Wales was performed to determine the use of local anaesthesia and day-case rates for inguinal hernia repair.

RESULTS

A total of 577 hernia repairs were performed during the study period. Of these, 369 (64%) repairs were performed under local anaesthesia (LA) and 208 (36%) under general anaesthesia (GA). Day-case repair was achieved in 70% (400) of cases. The day-case rates were significantly higher under LA compared to GA (82.6% versus 42.6%; P < 0.05). Patients operated under LA had lower postoperative analgesic requirements and lower incidence of urinary retention compared with the GA group (P < 0.05). There were 7 (1.2%) recurrences at a median follow-up of 5.1 years (range, 10.3–2.5 years). Postal questionnaire revealed higher satisfaction rates with LA compared to GA repair. Only 15% of surgeons in Wales offer the majority of their patients local anaesthetic repair.

CONCLUSIONS

The use of LA results in increased day-case rates, lesser postoperative analgesic requirements and fewer micturition problems. The excellent results obtained by specialist hernia centres can be reproduced by district general hospitals by increasing the use of LA to repair inguinal hernias.     

Transition from Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair to Robotic Transabdominal Preperitoneal Inguinal Hernia Repair: A Retrospective Review of a Single Surgeon’s Experience

Background

There is a paucity of literature comparing laparoscopic to robotic inguinal hernia repair. We present a single surgeon’s transition from laparoscopic totally extraperitoneal (L-TEP) to robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair and compare outcomes from the two approaches.

Methods

This retrospective review and analysis of prospectively collected data compare outcomes during the transition from L-TEP to R-TAPP inguinal hernia repair by a single surgeon at one institution. Operating times and surgical outcomes and complications are analyzed. All consecutive L-TEP cases from November 2012 to August 2014 and all consecutive R-TAPP cases from March 2013 to October 2015 were included in the analysis.

Results

A total of 157 and 118 patients underwent L-TEP and R-TAPP inguinal hernia repair, respectively. The groups were similar regarding demographics and ASA class. A significantly higher number of complex cases were performed in the R-TAPP group compared to L-TEP group (n = 11 vs. n = 1, p = 0.0001). Mean surgical times were nearly identical (69.12 ± 35.13 min, R-TAPP; 69.05 ± 26.31, L-TEP) as were intraoperative and postoperative complication rates—despite the significantly higher number of complex cases in the R-TAPP group.

Conclusions

This is the largest study in the literature comparing a single surgeon’s experience transitioning from L-TEP to R-TAPP inguinal hernia repair. Results from the R-TAPP cases were similar to those achieved from laparoscopic cases. The robotic platform may have facilitated the execution of complex hernia cases during the proficiency phase.

     

Endoscopic surgeons’ preferences for inguinal hernia repair: TEP, TAPP, or OPEN

Introduction

The use of endoscopic inguinal hernia repair has slowly increased in the past years, but the indications have remained vague. Some surgeons perform a tailored approach depending on patient or hernia characteristics, whereas others perform the same approach and technique for all hernias.

Methods

Based on these principles, a survey of 19 questions was conducted during the 18th Congress of the European Association of Endoscopic Surgeons, which took place in Geneva, Switzerland, in 2010, to determine surgeons’ preference depending on the hernia and the patient.

Results

All surgeons who attended the session (N?=?100) responded to all questions. Eighty two percent of surgeons preferred a tailored approach, whereas 18?% used the same technique in all cases. Endoscopic techniques are used more frequently than the open approach in bilateral (7 vs. 93?%) and recurrent hernias (19 vs. 81?%), whereas in primary unilateral hernias all three techniques were used with almost similar frequency (32?% open, 39?% TAPP vs. 29?% TEP). TAPP was used more frequently than TEP, and even those surgeons who are expert in TEP preferred to perform a TAPP in difficult hernias, such as in obese patients and large scrotal hernias. Based on the age of patients, the open approach is preferred in patients younger than 18 years and older than 70 years, whereas the endoscopic approach is preferred in young active males and females, with a trend to use TAPP (44?%) more frequently than TEP (40?%) in females. Surgeons tended to use the open (vs. endoscopic) approach in patients with hematologic disorders (58?% open vs. 42?% endoscopic), previous laparotomy (59?% open vs. 41?% endoscopic) or emergency surgery (66 vs. 33?% in incarcerated hernias and 74 vs. 26?% in strangulated hernia).

Conclusions

This survey showed that most surgeons who perform an endoscopic approach for inguinal hernia as the first option are convinced that not all hernias are good indications for this approach. On the other hand, most surgeons think that it is better to be able to offer patients an endoscopic technique or an open approach depending on the case.     

Consenting Practice for Open Inguinal Hernia Repairs – Are We Failing to Warn Patients of Serious Complications?

INTRODUCTION

Open inguinal hernia repairs are one of the most commonly performed procedures in the UK. The procedure can sometimes result in considerable morbidity. It is imperative that the consenting process for this procedure is meticulous. This allows the patient to make a fully informed decision as they are aware of potential complications. In turn, this reduces the risk of future litigation. The aim of this study was to examine the adequacy of consenting for open inguinal hernia repairs, in particular, focusing on serious risks associated with the procedure.

PATIENTS AND METHODS

The notes of male patients who had undergone open inguinal hernia repair over a 6-month period were identified by the IT department. Inclusion and exclusion criteria were defined, giving a total of 97 male patients. Their consent forms were examined, focusing on: (i) the complications mentioned; and (ii) the grade of the consentor. A proforma was filled in for each of these patients and the data collated.

RESULTS

Of the 97 patients in the study, 25.7% of patients were consented by a consultant, 54.6% by a specialist registrar, and 19.6% by a senior house officer/FY2. The most commonly recorded risks included infection (100%) and bleeding (100%). Serious complications such as chronic pain (consented for at an average of 14%), testicular complications (45.3%) and visceral injury (52.1%) were poorly accounted for at all levels.

CONCLUSIONS

Consultants and juniors alike are not adequately consenting patients for inguinal hernia repairs, omitting serious complications such as chronic pain, recurrence and testicular complications. This leaves surgical teams vulnerable to claims for negligence. Good consenting practice may ultimately benefit both patient and surgeon.     

The Repair of Incisional Hernia Following Roux-en-Y Gastric Bypass—With or Without Concomitant Abdominoplasty?

Background  Incisional hernia, found in up to 25% of patients, is a typical complication of open bariatric surgery. Methods  Open Roux-en-Y gastric bypass (RYGB) was performed in 204 patients. They have been followed-up for at least 6 months. Thirty-two patients in whom incisional hernia was diagnosed were divided into two groups—they were scheduled for hernia repair or hernia repair with abdominoplasty. The surgery was performed, on average, 20 months after RYGB operation. Fourteen patients [mean body mass 86.4 kg, mean body mass index (BMI) 30.0 kg/m²] have had hernias repaired. The mean duration of hospital stay was 7.2 days. Hernia repair along with abdominoplasty was performed in 18 patients with mean body mass 89.4 kg and BMI 31.5 kg/m². The mean duration of hospital stay was 8.7 days. Results  Both examined groups were similar in body mass, BMI, age, and duration of hospital stay (p > 0.05), as well as gender distribution. The wound infection was diagnosed in six patients. Conclusion  The simultaneous abdominoplasty does not prolong the time of hospital stay of the patients undergoing incisional hernia repair. Infection is the most frequent complication of incisional hernia repair.     

Simultaneous or Staged Bilateral Total Hip Arthroplasty? An Analysis of Complications in 14,460 Patients Using National Data

BackgroundSimultaneous bilateral total hip arthroplasty (SimBTHA) is often performed in younger, fitter patients with bilateral hip disease. If patients are deemed not suitable for SimBTHA due to concurrent comorbidity, it may be more appropriate to perform staged bilateral total hip arthroplasties (StBTHAs) 3-6 months apart to minimize complications and morbidity. Complication rates following hip arthroplasty are low and large national datasets are helpful for assessing these rare events. We aimed at comparing SimBTHA vs StBTHA in order to determine any differences in morbidity and mortality.MethodsHospital Episode Statistics data for all patients who underwent bilateral THAs in the English National Health Service between April 2005 and July 2014 were obtained. Patients were grouped into SimBTHAs (same day) or staged, with the second THA occurring between 3 and 6 months after the first. Medical and surgical complications were compared and total length of stay was assessed.ResultsA total of 2507 underwent SimBTHAs and 9915 had StBTHAs. SimBTHA patients were significantly younger (60.6 vs 65.5 years, P < .001) and more likely to be male, but had similar Charlson comorbidity scores. Compared to StBTHAs, patients undergoing SimBTHAs had a greater risk of pulmonary embolism, myocardial infarction, renal failure, chest infection, and inhospital death. Patients undergoing SimBTHAs had a significantly shorter overall hospital stay (8.9 vs 10.4 days). Patients undergoing SimBTHA at high-volume units had a lower average Charlson score and subsequent complication rate than low-volume units.ConclusionThese findings highlight the greater risks of SimBTHA in patients with Charlson score greater than 0 performed at lower-volume centers in England.