The best technique for inguinal hernia repair based on current evidence
Inguinal hernia is a very common condition. Unless the patient is very old, or if the patient has serious poorly controlled medical conditions which rendered any form of surgery, even minor ones, high risk, doctors would encourage patients to have the hernia repaired.
The alternative is of course to leave it alone. The trade-offs with this approach are that the hernia will get bigger and bigger, and it may interfere with the patient’s daily activities. Then there is a very small risk of intestinal herniation with the potentially dangerous squealae of bowel strangulation.
With the advent of laparoscopic techniques, laparoscopic inguinal hernia repair became available as an alternative for patients. There are two current techniques for laparoscopic repair, namely transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP).
Generally most surgeons prefer TEP. This is because TEP offers several advantages over TAPP, including less risk of injury to intra-abdominal organs like the intestines, fewer intra-abdominal adhesions, and no need to close a large peritoneal hole.
Here at Nexus Surgical, our preferred laparoscopic technique is TEP. We reserved TAPP for recurrence from a previous TEP repair, and that is a very rare occurrence.
The advantages of laparoscopic surgery, also known as keyhole surgery, over open surgery are quite established. These include including less postoperative pain, reduced need for painkillers, and faster return to regular activities. Most of our patients have their laparoscopic repair performed as day surgery, and most return to their work place within a week.
Such advantages of laparoscopic repair over open repair have been borne out by scientific medical studies. This is one of such study.
In this study, 660 patients were randomly assigned to either a TEP repair or an open repair (also known as Lichtenstein repair). The study then followed up these patients for 5 years.
Acute postoperative pain, measured as presence vs absence of pain at 1, 2, 3, 7, and 30 days after the procedure, was significantly less after TEP than after open repair.
For chronic pain and groin numbness, again TEP is superior to open surgery. The researchers found the incidence rate of chronic pain at 28% for the open group after 5 years compared with 14.9% for the TEP group. For groin sensation, the authors found that 22% of the open group reported impairments compared with 1% of the patients receiving TEP. It is no surprise that patients who received TEP returned to daily activities sooner and had fewer days off from work.
The study also noted that patients who received the TEP experienced more operative complications (6% vs 2%) and longer operating times than patients who received the Lichtenstein procedure, but the researchers wrote that the positive outcomes "counterbalance" that, and that complications had no long-term effects. Total costs and length of hospital stay turned out to be comparable for both procedures.
The risk of complications and how long the surgery takes may be a function of the experience of the surgeon. Indeed, the study found that the recurrence rates of the hernia were much lower when performed by experienced surgeons.
If we were to use the grading system used by the researchers to classify the experience level of the surgeons, the surgeons at Nexus Surgical would fall into level 3 (>25 procedures).
Here is the abstract of the study:
For those of you who prefer the full article, this paper is available for free download from the Internet:
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