Original Article

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Journal of Minimally Invasive Surgery 2023; 26(4): 190-197

Published online December 15, 2023

https://doi.org/10.7602/jmis.2023.26.4.190

© The Korean Society of Endo-Laparoscopic & Robotic Surgery

Perioperative complications of laparoscopic inguinal hernia repair in India: a prospective observational study

Vikram Saini1 , Amrutha Varshini R2 , Yashwant Singh Rathore1 , Sunil Chumber1 , Kamal Kataria1 , Richa Garg1

1Department of Surgical Discipline, All India Institute of Medical Sciences, New Delhi, India
2Department of Neurosurgery, National Institute of Mental Health and Neuro-Sciences, Bangalore, India

Correspondence to : Yashwant Singh Rathore
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
E-mail: dryashvant.r@gmail.com
https://orcid.org/0000-0002-0229-452X

Received: April 24, 2023; Revised: October 4, 2023; Accepted: November 16, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose: These days laparoscopic inguinal hernia surgery, both totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP), is a commonly performed procedure due to advancements in laparoscopic instruments and the availability of skilled laparoscopic surgeons. The purpose of this study was to compare the perioperative complications of these two procedures.
Methods: This was a prospective observational study between July 2019 and December 2020. Perioperative complications were compared with a 6-month follow-up. It included 144 patients, of whom 71 underwent TAPP repair and 73 underwent TEP repair. The selection was based on the surgeon’s choice.
Results: Early postoperative complications were scrotal edema (12 cases in TEP and 16 in TAPP), urinary retention (one case in TEP), ecchymosis (six cases in TEP and two in TAPP), and scrotal subcutaneous emphysema (two cases in TEP). On follow-up, seroma was found in a total of 22 cases, of which 12 were TEP and 10 were TAPP. While only one case of TAPP developed surgical site infection. There was no statistically significant difference in hospital stay between the two groups (p = 0.58). The pain scores significantly decreased throughout recovery and were comparable between the groups. Neither group experienced a recurrence during the 6-month follow-up. Fifty-eight patients developed Clavien-Dindo grade I complications, one had grade II, and three had grade IIIa complications.
Conclusion: With the increasing experience of the surgical fraternity in laparoscopic surgery, TEP and TAPP were proven to be comparable in terms of duration of surgery, postoperative complications, hospital stay, pain scores, and recurrence during the 6-month follow-up.

Keywords Laparoscopic surgery, Inguinal hernia, Minimally invasive surgery

Inguinal hernia is one of the most common problems that come into the domain of a general surgeon. With several advancements in the field of laparoscopic surgery, laparoscopic hernia repair (LHR) is now the most popular approach. Totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) mesh hernioplasty are the most common laparoscopic procedures for inguinal hernia patients these days. There are different opinions about intraoperative complications, postoperative course, and recurrence in various studies on LHR. The search for the best approach with minimal complications and recurrence in laparoscopic inguinal hernia surgery is still going on. In LHR, the experience of the surgeon plays a great role in early recovery, less pain, and fewer complications [1]. The present study was conducted with the objective of comparing intraoperative, immediate, early, and late postoperative complications of TEP and TAPP mesh hernioplasty performed by experienced laparoscopic surgeons with a 6-month follow-up. We also tried to find a better approach out of these two with respect to complications and recurrence in the 6-month follow-up period. The current study allowed the surgeon to choose the type of surgery to be performed on the patient so that the best results of a particular approach could be delivered to a patient as per the surgeon’s clinical judgment and skill.

This was a single-center, prospective, observational study of 144 patients (aged >18 years) who underwent LHR for groin hernias between July 1, 2019 and December 31, 2020, performed by seven experienced surgeons in our institution. Our institution is a high-output center, with 20 to 25 LHRs performed each month. Seven surgeons performed these surgeries. Each surgeon has performed more than 300 laparoscopic hernia surgeries (TEP and TAPP) for more than 5 years. The selection of the technique, either TEP or TAPP, was based on the surgeon’s preference. Patients with recurrent hernias, complicated inguinal hernias, i.e., obstructed or strangulated, laparoscopic hernia approaches converted to an open procedure, patients unfit for general anesthesia, patients with morbid obesity, and patients with any other immunocompromised state like human immunodeficiency virus-positive or any other risk factors for impaired healing like diabetes mellitus were excluded from this study. All patients were thoroughly questioned and examined on an outpatient department basis and on admission individually. They were admitted to our hospital 1 day before surgery or on the morning of surgery. The preanesthetic evaluation was performed by the corresponding anesthesia team. Part preparation was done using a hair clipper from the umbilicus to the mid-thigh. The procedure was performed with the patient under general anesthesia. Urinary bladder catheterization was done with a 14-French Foley catheter in all patients after induction. The patients were placed in the supine position with both arms by the patient’s side in bilateral repair or the contralateral arm by the patient’s side in unilateral repair. A single-dose injection of cefuroxime (1,500 mg) after a skin test was given intravenously as antibiotic prophylaxis preoperatively. Both TEP and TAPP were performed as per the three-port position and standard procedural guidelines with a 14 × 13-cm polypropylene mesh. Mesh was fixed with absorbable trackers at the level of Cooper’s ligaments and anterior abdominal wall muscles. The peritoneum was closed with V-Loc 180 (size, 3-0; Covidien) 15-cm absorbable polyglyconate knotless wound closure device. Adequate scrotal support was advised, and application was ensured starting in the immediate postoperative period. Twenty-four hours was considered an immediate postoperative period, and 1 to 7 postoperative days was considered an early postoperative period. The urinary catheter was removed in the morning postsurgery, and the patient was closely monitored for any urinary complaints, if present. Pain scores were recorded at 6 hours after the operation, at the time of discharge, and during follow-up based on a visual analogue scale (VAS) where 0 indicated no pain and 10 indicated the worst possible pain. The follow-up of patients was done at 1-week, 1-month, 3-month, and 6-month intervals. The complications were graded according to the Clavien-Dindo (CD) classification system.

Statistical analysis

The data was analyzed using Stata version 14 (StataCorp). Continuous and normally distributed data like age, body mass index (BMI), symptoms duration, and operation duration were presented in mean ± standard deviation. Categorical data like sex, American Society of Anesthesiologists (ASA) physical status (PS) classification, and hernia characteristics were presented using a number (%). Continuous and non-following normally distributed data like pain VAS scores and hospital stays were presented using the median and interquartile range (IQR). Continuous variables were compared by the Student t test (following the normal distribution) and the Wilcoxon Rank Sum test (not following the normal distribution). Within a group, pain VAS scores were compared with repeated measure analysis of variance (ANOVA). Categorical variables were compared by the chi-square test or Fisher exact test. A p-value of <0.05 was considered statistically significant.

A total of 180 patients underwent LHR during the study period. Of them, 144 patients were included in the study after applying exclusion criteria: 71 patients (49.3%) were selected by the operating surgeon for TAPP repair and 73 (50.7%) for TEP repair. A study flow chart is shown in Fig. 1.

Fig. 1. A study flow chart. LHS, laparoscopic hernia surgery; TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal.

Demographic profile

The demographic profile of the patients included in the study is shown in Table 1. The mean age of patients was 46.38 ± 16.98 years. The mean BMI was 26.48 ± 4.41 kg/m2 in the TEP group and 27.52 ± 4.29 kg/m2 in the TAPP group and was not considered statistically significant. The study found no statistically significant difference in the mean duration of symptoms or the ASA PS classification between the TEP and TAPP groups. The majority of the hernias were unilateral (81.3%) and bilateral (18.7%). The majority of the patients in both groups had an incomplete hernia (bubonocele or funicular hernia); more patients with a complete hernia (inguinoscrotal hernia) underwent TAPP repair (p = 0.01). There was no statistical difference in the reducibility of hernias among the patients undergoing TEP and TAPP repair (p = 0.06).

Table 1 . Baseline patient characteristics in TEP and TAPP group

CharacteristicTotalTEP groupTAPP groupp value
No. of patients1447371
Age (yr)46.38 ± 16.9847.17 ± 17.9345.57 ± 16.970.57
Sex0.36
Male140 (97.2)72 (98.6)68 (95.8)
Female4 (2.8)1 (1.4)3 (4.2)
Body mass index (kg/m2)26.99 ± 4.3726.48 ± 4.4127.52 ± 4.290.15
Symptoms duration (mo)18.16 ± 11.7516.77 ± 10.4819.59 ± 12.840.15
ASA PS classification0.51
I65 (45.1)35 (47.9)30 (42.3)
II79 (54.9)38 (52.1)41 (57.7)
No. of hernias0.43
Unilateral hernia117 (81.3)56 (76.7)61 (85.9)
Bilateral hernia27 (18.7)17 (23.3)10 (14.1)
Extent of hernia0.01
Incomplete hernia128 (88.9)70 (95.9)58 (81.7)
Complete hernia16 (11.1)3 (4.1)13 (18.3)
Hernia type0.38
Indirect hernia106 (73.6)49 (67.1)57 (80.3)
Direct hernia32 (22.2)20 (27.4)12 (16.9)
Direct one side and indirect the other side4 (2.8)1 (1.4)3 (4.2)
Pantaloon hernia2 (1.4)0 (0)2 (2.8)

Values are presented as number only, mean ± standard deviation, or number (%).

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal; ASA, American Society of Anesthesiologists; PS, physical status.



Intraoperative complications

There was no statistical difference in mean operative time between TEP and TAPP (p > 0.05). Three patients required open assistance in the reduction of their sac content (indirect hernia) via an inguinal incision, and these cases were excluded from the current study. The mean blood loss in both groups was not statistically significant (p = 0.28). No major visceral, vascular, or vas deferens injury was encountered during the study. All intraoperative complications are shown in Table 2. The intraoperative peritoneal breach was managed either by increasing the CO2 flow rate or by peritoneal decompression using a Veress needle puncture at Palmer’s point.

Table 2 . Intaoperative results of patients in the TEP and TAPP group

VariableTotalTEP group (n=73)TAPP group (n=71)p value
Operation time (min)
Unilateral (n = 117)65.76 ± 3.9465.14 ± 3.0166.33 ± 4.590.10
Bilateral (n = 27)88 ± 7.4986 ± 7.2091.40 ± 7.000.07
Blood loss (mL)25.66 ± 7.9126.37 ± 8.3324.93 ± 7.440.28
Visceral injury000NA
Vascular injury000NA
Vas deferens injury000NA

Values are presented as mean ± standard deviation or number only.

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal; NA, not applicable.



Postoperative complications

Scrotal edema was documented in 12 (16.4%) and 16 patients (22.5%) who underwent TEP and TAPP repair, respectively. All of them were resolved spontaneously by the end of 1 week with the application of scrotal support. The difference was found to be of no statistical significance (p = 0.40). Postoperative complications are shown in Table 3. Operative site skin ecchymosis was noted in eight patients (5.6%); out of them, six (8.2%) underwent TEP, and two (2.8%) underwent TAPP. All ecchymoses were nonprogressive and resolved spontaneously. Scrotal subcutaneous emphysema was reported in two patients (2.7%) who underwent TEP repair. They were managed by the scrotal support application. One patient who underwent TAPP developed urinary retention in the immediate postoperative period. It was managed by catheterization and the tablet tamsulosin. None of the patients developed a scrotal hematoma, testicular pain, or an immediate postoperative recurrence. Seroma was noticed at the 7-day follow-up. Twelve patients (16.4%) who underwent TEP repair developed seroma, compared with 10 (14.1%) in the TAPP group. Of these, only two patients (2.8%) in the TAPP group required a one-time aspiration during the follow-up. The rest of the patients were managed with supportive care. The difference in incidence did not have any statistical significance (p = 0.82) (Table 3). Only one patient (1.4%) in the TAPP group had a wound infection at a 7-day follow-up. It was a case of superficial surgical site infections (SSIs) at port sites. This patient had an uneventful recovery once the skin staples were removed and was started on oral antibiotics for 7 days. The median postoperative hospital stay was 2 days, with an IQR of 2–3 in both groups. The maximum postoperative hospital stay was 5 days, one in both groups, due to nonsurgical reasons (neurofibromatosis screening, pain control). None of the patients in either study group required readmission after discharge. Out of 144 patients, 58 (40.3%) developed CD grade I complications, one (0.7%) had grade II , and three (2.1%) had grade IIIa complications. As shown in Table 4, postoperative complications requiring intervention were categorized using the CD classification.

Table 3 . Postoperative complications of patients in the TEP and TAPP group

Postoperative complicationsTotal patients (n = 144)TEP group (n = 73)TAPP group (n = 71)p value
Scrotal edema28 (19.4)12 (16.4)16 (22.5)0.40
Ecchymosis8 (5.6)6 (8.2)2 (2.8)0.27
Scrotal subcutaneous emphysema2 (1.4)2 (2.7)0 (0)0.49
Urinary retention1 (0.7)0 (0)1 (1.4)0.12
Seroma22 (15.3)12 (16.4)10 (14.1)0.82
Surgical site infection1 (0.7)0 (0)1 (1.4)0.12
Hospital stay (day)2 (2–3)2 (2–3)2 (2–3)0.58

Values are presented as number (%) or median (interquartile range).

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal.



Table 4 . Postoperative complications in TEP and TAPP group with intervention done and the Clavien-Dindo classification grading

Postoperative complicationTEP group (n=73)TAPP group (n=71)InterventionClavien-Dindo grade
Scrotal edema12 (16.4)16 (22.5)Supportive care and analgesicsI
Seroma12 (16.4)8 (11.3)Supportive care and analgesicsI
0 (0)2 (2.8)Seroma aspirationIIIa
Ecchymosis6 (8.2)2 (2.8)Supportive care and analgesicsI
Scrotal subcutaneous emphysema2 (2.7)0 (0)Supportive care and analgesicsI
Urinary retention0 (0)1 (1.4)Single-time catheterization tablet (tamsulosin 0.4 mg)IIIa
Surgical site infection0 (0)1 (1.4)Removal of staples, antibioticsII

Values are presented as number (%).

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal.



Pain VAS score findings are summarized in Table 5. Pain VAS scores in both the TEP and TAPP groups were not statistically significant, but intergrouply, there was a significant improvement in the pain VAS score at each postoperative follow-up. The repeated measure ANOVA revealed a p-value of <0.01 and an effect size of 0.99. There was significant improvement noted at each point in time, as revealed through the pair-wise comparison with p < 0.01. None of the patients enrolled in the study developed recurrences during the 6-month follow-up period.

Table 5 . Pain VAS score in postoperative period and during follow-up in TEP and TAPP group

Pain VAS scoreTEP groupTAPP groupp value
Postoperative at 1 hour5 (5–6)5 (5–6)0.25
At discharge4 (4–5)4 (4–4)0.72
Postoperative duration
1 wk3 (3–4)3 (3–4)0.71
1 mo2 (2–2)2 (2–3)0.84
3 mo1 (1–1)1 (1–1)0.49
6 mo1 (0–1)1 (0–1)0.90

Values are presented as median (interquartile range).

VAS, visual analogue scale; TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal.


Currently, TEP and TAPP are the two standard techniques practiced worldwide. Several studies compare the two techniques by randomly assigning patients to each group. As aforementioned, the outcomes are undeniably dependent on the surgeon’s learning curve and interfere with the interpretation of results by acting as a confounder, especially when the study population is operated by a team of consultants at various stages of learning [1]. In this study, seven experienced laparoscopic surgeons were allowed to choose the procedure based on their clinical judgment and skill. The mean age in our study was 46.38 ± 16.98 years. This result closely correlates with two randomized controlled trials conducted previously [2,3]. In addition, 64.1% of our hernias were right-sided. In their study on the Indian population, Krishna et al. [2] reported that the majority of the hernias (62.3%) in their study were right-sided. This distribution matches the above-stated study and similar studies conducted in other countries [1,3,4,5]. There appears to be a higher rate of visceral (especially urinary bladder) and vascular injury in laparoscopic repair when compared to open surgery, especially with TAPP [6,7]. The nonrandomized trials of TEP and TAPP showed that inferior epigastric vessels are the most often injured among vascular injuries, and there is only one case of iliac vessel injury [7]. Another study observed that TEP and TAPP had similar epigastric vessel bleeding rates [8]. Our study encountered no visceral or major vascular injuries because experienced surgeons performed minimal and precise dissections. They were well aware of the plan of dissection and major vessels. We also excluded patients with a recurrence or a history of previous groin surgeries.

A pooled estimate from the systematic review by Hung et al. [8] showed that TEP resulted in lower scrotal and cord edema rates at immediate postoperative and 1 week after surgery. On the other hand, a study by Krishna et al. [2] reports significantly higher scrotal edema in the TAPP group (34%), compared to the TEP group (9.4%). Our study found a 19.4% incidence of scrotal edema and no statistical difference between these groups. So, the incidence of scrotal edema is comparable across different approaches by experienced hands. Seroma formation is a natural process that cannot be completely prevented following laparoscopic inguinal hernioplasty, especially in patients with direct and large indirect inguinal hernias. In one study, the range of seroma formation was between 0.5% and 12.2% after TEP repair, and between 3% and 8% for TAPP [9]. Krishna et al. [2] reported an incidence of seroma up to 28% after the first postoperative week, predominantly in the TEP group, but only 5.0% at the end of the first month, and most of the seromas were resolved without any intervention. In our study, seroma incidence was 15.3%, with no statistical difference in incidence among the two procedures. Our findings agree with those of Aiolfi et al. [4], which are among the recent meta-analyses published. All patients with seroma in our research improved with time, with the exception of two patients. So, we can postulate that the more experienced the surgeon is, the better the dissection and the lower the rate of seroma formation.

At our institute, we routinely give a single dose of antibiotic before surgery as routine surgical antibiotic prophylaxis, according to the National Institute for Health and Care Excellence guidelines [10]. Cai et al. [11], in their study on SSIs after inguinal hernia repair in low- and middle-HDI countries, including six studies from India, found that LHRs had a weighted pooled SSI rate of 0.4 infections per 100 laparoscopic repairs. Aiolfi et al. [4] found no difference between TEP and TAPP repair in terms of post-SSI. In our study, we encountered no deep-space or mesh infections. We had one case of superficial SSI that amounted to an SSI rate of 0.7 infections per 100 laparoscopic repairs.

Chen et al. [12], in their meta-analysis, analyzed the outcomes of TEP and TAPP repair and found that the short-term postoperative pain scores were significantly lower in the TEP group, whereas the scores beyond 6 months were comparable in both groups. On the other hand, Wei et al. [5] found no significant difference in short-term postoperative pain scores between TEP and TAPP in their meta-analysis. In our study, after 6 months of follow-up in both groups, the median VAS score was 1, reflecting careful and minimal dissection by experienced laparoscopic surgeons. A meta-analysis comparing TEP to TAPP revealed that the recurrence rates were comparable between the two groups [2,5,8,12]. They also found evidence to support the conclusion that the surgeon’s experience had a significant impact on the recurrence of the hernia [7,13,14]. In this study, procedures were performed by surgeons with experience above the minimum of 50 LHR, as recommended by Bracale et al. [15].

There are some limitations of the current study. This study is a small-scale observational study at a single institute, restricted in timespan due to academic obligations and in the number of study subjects by the ongoing SARS-CoV-2 pandemic. We observed no recurrences in 6 months. However, it is too early in the course to determine the recurrence rates accurately. Overall, this study has proven that in the hands of an experienced surgeon, the results of both LHR in terms of complications, duration of surgery, and hospital stay are good and comparable.

Both TEP and TAPP, performed by experienced hands, were comparable in terms of duration of surgery, postoperative complications, hospital stay, pain scores, and recurrence during the 6-month follow-up. The most commonly encountered postoperative complications in our study were scrotal edema (19.4%) and seroma formation (15.3%).

Ethical statements

Ethical approval was taken from the Institutional Ethics Committee of All India Institute of Medical Sciences, New Delhi (No. IECPG-373/29.05.2019). The informed written consent of all patients was obtained prior to the commencement of the study.

Authors’ contributions

Conceptualization, Formal analysis, Methodology: AVR, YSR

Data curation, Investigation: VS, AVR, YSR

Writing–original draft: VS, YSR

Writing–review & editing: all authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available on request from the corresponding author.

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Article

Original Article

Journal of Minimally Invasive Surgery 2023; 26(4): 190-197

Published online December 15, 2023 https://doi.org/10.7602/jmis.2023.26.4.190

Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.

Perioperative complications of laparoscopic inguinal hernia repair in India: a prospective observational study

Vikram Saini1 , Amrutha Varshini R2 , Yashwant Singh Rathore1 , Sunil Chumber1 , Kamal Kataria1 , Richa Garg1

1Department of Surgical Discipline, All India Institute of Medical Sciences, New Delhi, India
2Department of Neurosurgery, National Institute of Mental Health and Neuro-Sciences, Bangalore, India

Correspondence to:Yashwant Singh Rathore
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
E-mail: dryashvant.r@gmail.com
https://orcid.org/0000-0002-0229-452X

Received: April 24, 2023; Revised: October 4, 2023; Accepted: November 16, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose: These days laparoscopic inguinal hernia surgery, both totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP), is a commonly performed procedure due to advancements in laparoscopic instruments and the availability of skilled laparoscopic surgeons. The purpose of this study was to compare the perioperative complications of these two procedures.
Methods: This was a prospective observational study between July 2019 and December 2020. Perioperative complications were compared with a 6-month follow-up. It included 144 patients, of whom 71 underwent TAPP repair and 73 underwent TEP repair. The selection was based on the surgeon’s choice.
Results: Early postoperative complications were scrotal edema (12 cases in TEP and 16 in TAPP), urinary retention (one case in TEP), ecchymosis (six cases in TEP and two in TAPP), and scrotal subcutaneous emphysema (two cases in TEP). On follow-up, seroma was found in a total of 22 cases, of which 12 were TEP and 10 were TAPP. While only one case of TAPP developed surgical site infection. There was no statistically significant difference in hospital stay between the two groups (p = 0.58). The pain scores significantly decreased throughout recovery and were comparable between the groups. Neither group experienced a recurrence during the 6-month follow-up. Fifty-eight patients developed Clavien-Dindo grade I complications, one had grade II, and three had grade IIIa complications.
Conclusion: With the increasing experience of the surgical fraternity in laparoscopic surgery, TEP and TAPP were proven to be comparable in terms of duration of surgery, postoperative complications, hospital stay, pain scores, and recurrence during the 6-month follow-up.

Keywords: Laparoscopic surgery, Inguinal hernia, Minimally invasive surgery

INTRODUCTION

Inguinal hernia is one of the most common problems that come into the domain of a general surgeon. With several advancements in the field of laparoscopic surgery, laparoscopic hernia repair (LHR) is now the most popular approach. Totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) mesh hernioplasty are the most common laparoscopic procedures for inguinal hernia patients these days. There are different opinions about intraoperative complications, postoperative course, and recurrence in various studies on LHR. The search for the best approach with minimal complications and recurrence in laparoscopic inguinal hernia surgery is still going on. In LHR, the experience of the surgeon plays a great role in early recovery, less pain, and fewer complications [1]. The present study was conducted with the objective of comparing intraoperative, immediate, early, and late postoperative complications of TEP and TAPP mesh hernioplasty performed by experienced laparoscopic surgeons with a 6-month follow-up. We also tried to find a better approach out of these two with respect to complications and recurrence in the 6-month follow-up period. The current study allowed the surgeon to choose the type of surgery to be performed on the patient so that the best results of a particular approach could be delivered to a patient as per the surgeon’s clinical judgment and skill.

METHODS

This was a single-center, prospective, observational study of 144 patients (aged >18 years) who underwent LHR for groin hernias between July 1, 2019 and December 31, 2020, performed by seven experienced surgeons in our institution. Our institution is a high-output center, with 20 to 25 LHRs performed each month. Seven surgeons performed these surgeries. Each surgeon has performed more than 300 laparoscopic hernia surgeries (TEP and TAPP) for more than 5 years. The selection of the technique, either TEP or TAPP, was based on the surgeon’s preference. Patients with recurrent hernias, complicated inguinal hernias, i.e., obstructed or strangulated, laparoscopic hernia approaches converted to an open procedure, patients unfit for general anesthesia, patients with morbid obesity, and patients with any other immunocompromised state like human immunodeficiency virus-positive or any other risk factors for impaired healing like diabetes mellitus were excluded from this study. All patients were thoroughly questioned and examined on an outpatient department basis and on admission individually. They were admitted to our hospital 1 day before surgery or on the morning of surgery. The preanesthetic evaluation was performed by the corresponding anesthesia team. Part preparation was done using a hair clipper from the umbilicus to the mid-thigh. The procedure was performed with the patient under general anesthesia. Urinary bladder catheterization was done with a 14-French Foley catheter in all patients after induction. The patients were placed in the supine position with both arms by the patient’s side in bilateral repair or the contralateral arm by the patient’s side in unilateral repair. A single-dose injection of cefuroxime (1,500 mg) after a skin test was given intravenously as antibiotic prophylaxis preoperatively. Both TEP and TAPP were performed as per the three-port position and standard procedural guidelines with a 14 × 13-cm polypropylene mesh. Mesh was fixed with absorbable trackers at the level of Cooper’s ligaments and anterior abdominal wall muscles. The peritoneum was closed with V-Loc 180 (size, 3-0; Covidien) 15-cm absorbable polyglyconate knotless wound closure device. Adequate scrotal support was advised, and application was ensured starting in the immediate postoperative period. Twenty-four hours was considered an immediate postoperative period, and 1 to 7 postoperative days was considered an early postoperative period. The urinary catheter was removed in the morning postsurgery, and the patient was closely monitored for any urinary complaints, if present. Pain scores were recorded at 6 hours after the operation, at the time of discharge, and during follow-up based on a visual analogue scale (VAS) where 0 indicated no pain and 10 indicated the worst possible pain. The follow-up of patients was done at 1-week, 1-month, 3-month, and 6-month intervals. The complications were graded according to the Clavien-Dindo (CD) classification system.

Statistical analysis

The data was analyzed using Stata version 14 (StataCorp). Continuous and normally distributed data like age, body mass index (BMI), symptoms duration, and operation duration were presented in mean ± standard deviation. Categorical data like sex, American Society of Anesthesiologists (ASA) physical status (PS) classification, and hernia characteristics were presented using a number (%). Continuous and non-following normally distributed data like pain VAS scores and hospital stays were presented using the median and interquartile range (IQR). Continuous variables were compared by the Student t test (following the normal distribution) and the Wilcoxon Rank Sum test (not following the normal distribution). Within a group, pain VAS scores were compared with repeated measure analysis of variance (ANOVA). Categorical variables were compared by the chi-square test or Fisher exact test. A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 180 patients underwent LHR during the study period. Of them, 144 patients were included in the study after applying exclusion criteria: 71 patients (49.3%) were selected by the operating surgeon for TAPP repair and 73 (50.7%) for TEP repair. A study flow chart is shown in Fig. 1.

Figure 1. A study flow chart. LHS, laparoscopic hernia surgery; TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal.

Demographic profile

The demographic profile of the patients included in the study is shown in Table 1. The mean age of patients was 46.38 ± 16.98 years. The mean BMI was 26.48 ± 4.41 kg/m2 in the TEP group and 27.52 ± 4.29 kg/m2 in the TAPP group and was not considered statistically significant. The study found no statistically significant difference in the mean duration of symptoms or the ASA PS classification between the TEP and TAPP groups. The majority of the hernias were unilateral (81.3%) and bilateral (18.7%). The majority of the patients in both groups had an incomplete hernia (bubonocele or funicular hernia); more patients with a complete hernia (inguinoscrotal hernia) underwent TAPP repair (p = 0.01). There was no statistical difference in the reducibility of hernias among the patients undergoing TEP and TAPP repair (p = 0.06).

Table 1 . Baseline patient characteristics in TEP and TAPP group.

CharacteristicTotalTEP groupTAPP groupp value
No. of patients1447371
Age (yr)46.38 ± 16.9847.17 ± 17.9345.57 ± 16.970.57
Sex0.36
Male140 (97.2)72 (98.6)68 (95.8)
Female4 (2.8)1 (1.4)3 (4.2)
Body mass index (kg/m2)26.99 ± 4.3726.48 ± 4.4127.52 ± 4.290.15
Symptoms duration (mo)18.16 ± 11.7516.77 ± 10.4819.59 ± 12.840.15
ASA PS classification0.51
I65 (45.1)35 (47.9)30 (42.3)
II79 (54.9)38 (52.1)41 (57.7)
No. of hernias0.43
Unilateral hernia117 (81.3)56 (76.7)61 (85.9)
Bilateral hernia27 (18.7)17 (23.3)10 (14.1)
Extent of hernia0.01
Incomplete hernia128 (88.9)70 (95.9)58 (81.7)
Complete hernia16 (11.1)3 (4.1)13 (18.3)
Hernia type0.38
Indirect hernia106 (73.6)49 (67.1)57 (80.3)
Direct hernia32 (22.2)20 (27.4)12 (16.9)
Direct one side and indirect the other side4 (2.8)1 (1.4)3 (4.2)
Pantaloon hernia2 (1.4)0 (0)2 (2.8)

Values are presented as number only, mean ± standard deviation, or number (%)..

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal; ASA, American Society of Anesthesiologists; PS, physical status..



Intraoperative complications

There was no statistical difference in mean operative time between TEP and TAPP (p > 0.05). Three patients required open assistance in the reduction of their sac content (indirect hernia) via an inguinal incision, and these cases were excluded from the current study. The mean blood loss in both groups was not statistically significant (p = 0.28). No major visceral, vascular, or vas deferens injury was encountered during the study. All intraoperative complications are shown in Table 2. The intraoperative peritoneal breach was managed either by increasing the CO2 flow rate or by peritoneal decompression using a Veress needle puncture at Palmer’s point.

Table 2 . Intaoperative results of patients in the TEP and TAPP group.

VariableTotalTEP group (n=73)TAPP group (n=71)p value
Operation time (min)
Unilateral (n = 117)65.76 ± 3.9465.14 ± 3.0166.33 ± 4.590.10
Bilateral (n = 27)88 ± 7.4986 ± 7.2091.40 ± 7.000.07
Blood loss (mL)25.66 ± 7.9126.37 ± 8.3324.93 ± 7.440.28
Visceral injury000NA
Vascular injury000NA
Vas deferens injury000NA

Values are presented as mean ± standard deviation or number only..

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal; NA, not applicable..



Postoperative complications

Scrotal edema was documented in 12 (16.4%) and 16 patients (22.5%) who underwent TEP and TAPP repair, respectively. All of them were resolved spontaneously by the end of 1 week with the application of scrotal support. The difference was found to be of no statistical significance (p = 0.40). Postoperative complications are shown in Table 3. Operative site skin ecchymosis was noted in eight patients (5.6%); out of them, six (8.2%) underwent TEP, and two (2.8%) underwent TAPP. All ecchymoses were nonprogressive and resolved spontaneously. Scrotal subcutaneous emphysema was reported in two patients (2.7%) who underwent TEP repair. They were managed by the scrotal support application. One patient who underwent TAPP developed urinary retention in the immediate postoperative period. It was managed by catheterization and the tablet tamsulosin. None of the patients developed a scrotal hematoma, testicular pain, or an immediate postoperative recurrence. Seroma was noticed at the 7-day follow-up. Twelve patients (16.4%) who underwent TEP repair developed seroma, compared with 10 (14.1%) in the TAPP group. Of these, only two patients (2.8%) in the TAPP group required a one-time aspiration during the follow-up. The rest of the patients were managed with supportive care. The difference in incidence did not have any statistical significance (p = 0.82) (Table 3). Only one patient (1.4%) in the TAPP group had a wound infection at a 7-day follow-up. It was a case of superficial surgical site infections (SSIs) at port sites. This patient had an uneventful recovery once the skin staples were removed and was started on oral antibiotics for 7 days. The median postoperative hospital stay was 2 days, with an IQR of 2–3 in both groups. The maximum postoperative hospital stay was 5 days, one in both groups, due to nonsurgical reasons (neurofibromatosis screening, pain control). None of the patients in either study group required readmission after discharge. Out of 144 patients, 58 (40.3%) developed CD grade I complications, one (0.7%) had grade II , and three (2.1%) had grade IIIa complications. As shown in Table 4, postoperative complications requiring intervention were categorized using the CD classification.

Table 3 . Postoperative complications of patients in the TEP and TAPP group.

Postoperative complicationsTotal patients (n = 144)TEP group (n = 73)TAPP group (n = 71)p value
Scrotal edema28 (19.4)12 (16.4)16 (22.5)0.40
Ecchymosis8 (5.6)6 (8.2)2 (2.8)0.27
Scrotal subcutaneous emphysema2 (1.4)2 (2.7)0 (0)0.49
Urinary retention1 (0.7)0 (0)1 (1.4)0.12
Seroma22 (15.3)12 (16.4)10 (14.1)0.82
Surgical site infection1 (0.7)0 (0)1 (1.4)0.12
Hospital stay (day)2 (2–3)2 (2–3)2 (2–3)0.58

Values are presented as number (%) or median (interquartile range)..

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal..



Table 4 . Postoperative complications in TEP and TAPP group with intervention done and the Clavien-Dindo classification grading.

Postoperative complicationTEP group (n=73)TAPP group (n=71)InterventionClavien-Dindo grade
Scrotal edema12 (16.4)16 (22.5)Supportive care and analgesicsI
Seroma12 (16.4)8 (11.3)Supportive care and analgesicsI
0 (0)2 (2.8)Seroma aspirationIIIa
Ecchymosis6 (8.2)2 (2.8)Supportive care and analgesicsI
Scrotal subcutaneous emphysema2 (2.7)0 (0)Supportive care and analgesicsI
Urinary retention0 (0)1 (1.4)Single-time catheterization tablet (tamsulosin 0.4 mg)IIIa
Surgical site infection0 (0)1 (1.4)Removal of staples, antibioticsII

Values are presented as number (%)..

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal..



Pain VAS score findings are summarized in Table 5. Pain VAS scores in both the TEP and TAPP groups were not statistically significant, but intergrouply, there was a significant improvement in the pain VAS score at each postoperative follow-up. The repeated measure ANOVA revealed a p-value of <0.01 and an effect size of 0.99. There was significant improvement noted at each point in time, as revealed through the pair-wise comparison with p < 0.01. None of the patients enrolled in the study developed recurrences during the 6-month follow-up period.

Table 5 . Pain VAS score in postoperative period and during follow-up in TEP and TAPP group.

Pain VAS scoreTEP groupTAPP groupp value
Postoperative at 1 hour5 (5–6)5 (5–6)0.25
At discharge4 (4–5)4 (4–4)0.72
Postoperative duration
1 wk3 (3–4)3 (3–4)0.71
1 mo2 (2–2)2 (2–3)0.84
3 mo1 (1–1)1 (1–1)0.49
6 mo1 (0–1)1 (0–1)0.90

Values are presented as median (interquartile range)..

VAS, visual analogue scale; TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal..


DISCUSSION

Currently, TEP and TAPP are the two standard techniques practiced worldwide. Several studies compare the two techniques by randomly assigning patients to each group. As aforementioned, the outcomes are undeniably dependent on the surgeon’s learning curve and interfere with the interpretation of results by acting as a confounder, especially when the study population is operated by a team of consultants at various stages of learning [1]. In this study, seven experienced laparoscopic surgeons were allowed to choose the procedure based on their clinical judgment and skill. The mean age in our study was 46.38 ± 16.98 years. This result closely correlates with two randomized controlled trials conducted previously [2,3]. In addition, 64.1% of our hernias were right-sided. In their study on the Indian population, Krishna et al. [2] reported that the majority of the hernias (62.3%) in their study were right-sided. This distribution matches the above-stated study and similar studies conducted in other countries [1,3,4,5]. There appears to be a higher rate of visceral (especially urinary bladder) and vascular injury in laparoscopic repair when compared to open surgery, especially with TAPP [6,7]. The nonrandomized trials of TEP and TAPP showed that inferior epigastric vessels are the most often injured among vascular injuries, and there is only one case of iliac vessel injury [7]. Another study observed that TEP and TAPP had similar epigastric vessel bleeding rates [8]. Our study encountered no visceral or major vascular injuries because experienced surgeons performed minimal and precise dissections. They were well aware of the plan of dissection and major vessels. We also excluded patients with a recurrence or a history of previous groin surgeries.

A pooled estimate from the systematic review by Hung et al. [8] showed that TEP resulted in lower scrotal and cord edema rates at immediate postoperative and 1 week after surgery. On the other hand, a study by Krishna et al. [2] reports significantly higher scrotal edema in the TAPP group (34%), compared to the TEP group (9.4%). Our study found a 19.4% incidence of scrotal edema and no statistical difference between these groups. So, the incidence of scrotal edema is comparable across different approaches by experienced hands. Seroma formation is a natural process that cannot be completely prevented following laparoscopic inguinal hernioplasty, especially in patients with direct and large indirect inguinal hernias. In one study, the range of seroma formation was between 0.5% and 12.2% after TEP repair, and between 3% and 8% for TAPP [9]. Krishna et al. [2] reported an incidence of seroma up to 28% after the first postoperative week, predominantly in the TEP group, but only 5.0% at the end of the first month, and most of the seromas were resolved without any intervention. In our study, seroma incidence was 15.3%, with no statistical difference in incidence among the two procedures. Our findings agree with those of Aiolfi et al. [4], which are among the recent meta-analyses published. All patients with seroma in our research improved with time, with the exception of two patients. So, we can postulate that the more experienced the surgeon is, the better the dissection and the lower the rate of seroma formation.

At our institute, we routinely give a single dose of antibiotic before surgery as routine surgical antibiotic prophylaxis, according to the National Institute for Health and Care Excellence guidelines [10]. Cai et al. [11], in their study on SSIs after inguinal hernia repair in low- and middle-HDI countries, including six studies from India, found that LHRs had a weighted pooled SSI rate of 0.4 infections per 100 laparoscopic repairs. Aiolfi et al. [4] found no difference between TEP and TAPP repair in terms of post-SSI. In our study, we encountered no deep-space or mesh infections. We had one case of superficial SSI that amounted to an SSI rate of 0.7 infections per 100 laparoscopic repairs.

Chen et al. [12], in their meta-analysis, analyzed the outcomes of TEP and TAPP repair and found that the short-term postoperative pain scores were significantly lower in the TEP group, whereas the scores beyond 6 months were comparable in both groups. On the other hand, Wei et al. [5] found no significant difference in short-term postoperative pain scores between TEP and TAPP in their meta-analysis. In our study, after 6 months of follow-up in both groups, the median VAS score was 1, reflecting careful and minimal dissection by experienced laparoscopic surgeons. A meta-analysis comparing TEP to TAPP revealed that the recurrence rates were comparable between the two groups [2,5,8,12]. They also found evidence to support the conclusion that the surgeon’s experience had a significant impact on the recurrence of the hernia [7,13,14]. In this study, procedures were performed by surgeons with experience above the minimum of 50 LHR, as recommended by Bracale et al. [15].

There are some limitations of the current study. This study is a small-scale observational study at a single institute, restricted in timespan due to academic obligations and in the number of study subjects by the ongoing SARS-CoV-2 pandemic. We observed no recurrences in 6 months. However, it is too early in the course to determine the recurrence rates accurately. Overall, this study has proven that in the hands of an experienced surgeon, the results of both LHR in terms of complications, duration of surgery, and hospital stay are good and comparable.

Both TEP and TAPP, performed by experienced hands, were comparable in terms of duration of surgery, postoperative complications, hospital stay, pain scores, and recurrence during the 6-month follow-up. The most commonly encountered postoperative complications in our study were scrotal edema (19.4%) and seroma formation (15.3%).

Notes

Ethical statements

Ethical approval was taken from the Institutional Ethics Committee of All India Institute of Medical Sciences, New Delhi (No. IECPG-373/29.05.2019). The informed written consent of all patients was obtained prior to the commencement of the study.

Authors’ contributions

Conceptualization, Formal analysis, Methodology: AVR, YSR

Data curation, Investigation: VS, AVR, YSR

Writing–original draft: VS, YSR

Writing–review & editing: all authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available on request from the corresponding author.

Fig 1.

Figure 1.A study flow chart. LHS, laparoscopic hernia surgery; TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal.
Journal of Minimally Invasive Surgery 2023; 26: 190-197https://doi.org/10.7602/jmis.2023.26.4.190

Table 1 . Baseline patient characteristics in TEP and TAPP group.

CharacteristicTotalTEP groupTAPP groupp value
No. of patients1447371
Age (yr)46.38 ± 16.9847.17 ± 17.9345.57 ± 16.970.57
Sex0.36
Male140 (97.2)72 (98.6)68 (95.8)
Female4 (2.8)1 (1.4)3 (4.2)
Body mass index (kg/m2)26.99 ± 4.3726.48 ± 4.4127.52 ± 4.290.15
Symptoms duration (mo)18.16 ± 11.7516.77 ± 10.4819.59 ± 12.840.15
ASA PS classification0.51
I65 (45.1)35 (47.9)30 (42.3)
II79 (54.9)38 (52.1)41 (57.7)
No. of hernias0.43
Unilateral hernia117 (81.3)56 (76.7)61 (85.9)
Bilateral hernia27 (18.7)17 (23.3)10 (14.1)
Extent of hernia0.01
Incomplete hernia128 (88.9)70 (95.9)58 (81.7)
Complete hernia16 (11.1)3 (4.1)13 (18.3)
Hernia type0.38
Indirect hernia106 (73.6)49 (67.1)57 (80.3)
Direct hernia32 (22.2)20 (27.4)12 (16.9)
Direct one side and indirect the other side4 (2.8)1 (1.4)3 (4.2)
Pantaloon hernia2 (1.4)0 (0)2 (2.8)

Values are presented as number only, mean ± standard deviation, or number (%)..

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal; ASA, American Society of Anesthesiologists; PS, physical status..


Table 2 . Intaoperative results of patients in the TEP and TAPP group.

VariableTotalTEP group (n=73)TAPP group (n=71)p value
Operation time (min)
Unilateral (n = 117)65.76 ± 3.9465.14 ± 3.0166.33 ± 4.590.10
Bilateral (n = 27)88 ± 7.4986 ± 7.2091.40 ± 7.000.07
Blood loss (mL)25.66 ± 7.9126.37 ± 8.3324.93 ± 7.440.28
Visceral injury000NA
Vascular injury000NA
Vas deferens injury000NA

Values are presented as mean ± standard deviation or number only..

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal; NA, not applicable..


Table 3 . Postoperative complications of patients in the TEP and TAPP group.

Postoperative complicationsTotal patients (n = 144)TEP group (n = 73)TAPP group (n = 71)p value
Scrotal edema28 (19.4)12 (16.4)16 (22.5)0.40
Ecchymosis8 (5.6)6 (8.2)2 (2.8)0.27
Scrotal subcutaneous emphysema2 (1.4)2 (2.7)0 (0)0.49
Urinary retention1 (0.7)0 (0)1 (1.4)0.12
Seroma22 (15.3)12 (16.4)10 (14.1)0.82
Surgical site infection1 (0.7)0 (0)1 (1.4)0.12
Hospital stay (day)2 (2–3)2 (2–3)2 (2–3)0.58

Values are presented as number (%) or median (interquartile range)..

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal..


Table 4 . Postoperative complications in TEP and TAPP group with intervention done and the Clavien-Dindo classification grading.

Postoperative complicationTEP group (n=73)TAPP group (n=71)InterventionClavien-Dindo grade
Scrotal edema12 (16.4)16 (22.5)Supportive care and analgesicsI
Seroma12 (16.4)8 (11.3)Supportive care and analgesicsI
0 (0)2 (2.8)Seroma aspirationIIIa
Ecchymosis6 (8.2)2 (2.8)Supportive care and analgesicsI
Scrotal subcutaneous emphysema2 (2.7)0 (0)Supportive care and analgesicsI
Urinary retention0 (0)1 (1.4)Single-time catheterization tablet (tamsulosin 0.4 mg)IIIa
Surgical site infection0 (0)1 (1.4)Removal of staples, antibioticsII

Values are presented as number (%)..

TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal..


Table 5 . Pain VAS score in postoperative period and during follow-up in TEP and TAPP group.

Pain VAS scoreTEP groupTAPP groupp value
Postoperative at 1 hour5 (5–6)5 (5–6)0.25
At discharge4 (4–5)4 (4–4)0.72
Postoperative duration
1 wk3 (3–4)3 (3–4)0.71
1 mo2 (2–2)2 (2–3)0.84
3 mo1 (1–1)1 (1–1)0.49
6 mo1 (0–1)1 (0–1)0.90

Values are presented as median (interquartile range)..

VAS, visual analogue scale; TEP, totally extraperitoneal; TAPP, transabdominal preperitoneal..


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