Comparison of the Effects of Laparoscopic Hernia Repair and Lichtenstein Tension-Free Hernia Repair

Abstract

Objective:

To compare the effects of laparoscopic inguinal hernia repair (LIHR) and Lichtenstein tension-free inguinal hernia repair and to explore the safety and feasibility of LIHR as well as the advantages and disadvantages of these procedures.

Subjects and Methods:

In total, 252 patients with inguinal hernia were equally randomized into the transabdominal preperitoneal (TAPP) repair, totally extraperitoneal (TEP) repair, and Lichtenstein tension-free hernia repair groups (n=84 each). Operating time, postoperative pain scores, postoperative scrotal seroma, postoperative local esthesiodermia, postoperative chronic pains, postoperative long-term hernia relapse, and costs of hospitalization were compared among the three groups.

Results:

All laparoscopic operations were performed smoothly without intraoperative conversion to open surgery. The LIHR groups showed significantly better effects on postoperative pains and hernia recurrence than the Lichtenstein tension-free herniorrhaphy group (P<.05), but with a significantly higher hospitalization cost (P<.05). The occurrence rate of postoperative scrotal seroma or hydrops in the TAPP, TEP, and Lichtenstein groups was 11 (13.10%), 13 (15.48%), and 6 (7.14%), respectively. No significant differences among the operating time, postoperative local esthesiodermia, or postoperative chronic pains of the groups were observed (P>.05).

Conclusions:

LIHR is a safe and feasible procedure. It has significantly better effects on postoperative pains and hernia relapse than Lichtenstein tension-free hernia repair.

Introduction

The treatment of inguinal hernia has had a history of more than 100 years since the initiation of modern hernia surgery by Bassini in 1887. Nowadays, no other medical condition in general surgery can be treated with so many optional procedures as inguinal hernia. Inguinal hernia repair can be classified into three categories: (1) simple saturation, such as the Bassini, Halsted, Andrews, Shouldice, and McVay methods; (2) tension-free open repair, including repair to the posterior wall of the inguinal canal like the Lichtenstein method and repair to the myopectineal orifice such as the Stoppa, Kugel, and modified Kugel methods as well as subsequent Prolene™ (Ethicon, a Johnson & Johnson Company, Somerville, NJ) hernia system and Ultrapro™ (Ethicon)hernia system methods; and (3) laparoscopic inguinal hernia repair (LIHR), which include the collar extension closure, mesh transplantation, intraperitoneal onlay mesh, transabdominal preperitoneal (TAPP) repair, and totally extraperitoneal (TEP) methods.

Although the report concerning tension-free hernia repair released by Lichtenstein et al.¹ in 1989 marked the beginning of the tension-free age of inguinal hernia repair, the development of minimally invasive surgery promoted the wide application and development of laparoscopy in hernia surgery. LIHR emerged in the 1990s, and nowadays TAPP and TEP are the two primarily adopted procedures. Despite the same repair basis, TAPP and TEP differ in the pathway into the preperitoneal space: the former takes the peritoneal cavity as the route, whereas the latter does not, thereby avoiding intraperitoneal complications to the maximum.²

Although all the surgical procedures applied in the treatment of inguinal hernia nowadays are rational in technique, they are different in repair principles as well as in applicable populations. Recent years have seen the increasing applications of the Lichtenstein and TAPP or TEP methods for patients with inguinal hernia in clinical practice, but scholars are holding different views to their effects.

Therefore, in the current study, the effects of TAPP, TEP, and Lichtenstein tension-free hernia repair on operating time, postoperative hospital stay, operation complications, postoperative pain score, and postoperative hernia relapse rate were compared. The safety and feasibility of LIHR, as well as the advantages and disadvantages of LIHR and Lichtenstein repair, were further explored.

Subjects and Methods

General data

In total, 252 patients with inguinal hernia who received treatment between March 2005 and March 2010 were equally randomized into the TAPP, TEP, and Lichtenstein groups (n=84 each). Each group was surgically treated by two surgeons. The recruited surgeons must have met the following requirements: they had performed more than 30 Lichtenstein operations and more than 20 TAPP and TEP operations. Hernias were classified in line with the amended classification method by the Chinese Academy of Hernia and Abdominal Wall in August 2003.³ The general data of different groups are summarized in Table 1. This study was conducted in accordance with the Declaration of Helsinki. This study was conducted with approval from the Ethics Committee of The First People's Hospital of Wenling, Wenling, Zhejiang, China. Written informed consent was obtained from all participants.

Table 1.

Comparisons of the Data Among the Three Different Groups

		Sex		Hernia typing
Group	Age (years)	Male	Female	Indirect	Direct	Femoral	I	II	III	IV
TAPP	48.23±13.20	70	14	77	6	1	10	63	9	2
TEP	48.25±17.09	71	13	73	8	3	6	70	7	1
Lichtenstein	52.12±17.46	69	15	70	10	4	12	57	10	5
F value (chi-squared)	0.404	0.171		3.086			7.125
P value	0.670	.918		.543			.309

TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal.

Surgical procedures

The Lichtenstein group

Continuous epidural anesthesia, skin opening, and the anatomy of the inguinal canal were performed in the same way as those done in the Bassini method. The hernia sac was totally dissected (if the sac was large, the proximal section would be transected, sewed, and then pushed into the peritoneal cavity through the internal ring). Purse-string suturing was performed at the neck of the sac, and the spermatic cord was subsequently isolated. A 6-×11-cm Vypro II^® (Ethicon) patch of mesh was placed anterior to the transverse fascia and posterior to the spermatic cord, with the mesh sutured with the abdominal internal oblique muscle, conjoined tendon, the periosteum of the pubic tubercule, and inguinal ligament for fixation. The mesh close to the hernia ring was cut open to surround the spermatic cord and sutured. The interspace for the spermatic cord to pass through should not be too narrow, with the diameter of an index finger tip as the optimum, to prevent the occurrence of testicular ischemic atrophy. All type I–IV hernias were treated with meshes.

The TAPP group

The TAPP technique proposed by Dion and Morin⁴ was adopted. The procedure was performed with the patient under tracheal intubation plus general intravenous anesthesia. A pneumoperitoneum pressure between 9 mm Hg and 12 mm Hg (1 mm Hg=0.133 kPa) was set up. A trocar with a diameter of 10 mm was inserted at the inferior margin of the navel for observation use. A trocar with a diameter of 5 mm was inserted at the exterior margin of the umbilicus–paralleled rectus abdominis on the lesion side, and another with the same diameter was inserted between the umbilicus and the anterosuperior iliac spine on the opposite side. Under a laparoscope, an arc incision 2 cm distant from the superior margin of the deep ring was made in the peritoneum. The preperitoneal space was sharply isolated, the hernia sac was drawn back into the peritoneal cavity at the sac neck, and the neck was then ligated. For a hernia dropping into the scrotum, with part of the sac excluded in situ, the proximal part was drawn into the peritoneal cavity, and high ligation was then performed at the sac neck. The peritoneum was separated toward the periphery from the abdominal wall defect at the margin of the hernia ring to expose the inferior abdominal wall vessels, conjoined tendon, the arc margin of the transverse abdominal muscle, spermatic cord, crural ligament, and pectineal ligament. The separation reached the iliac crest outward, the site 3 cm superior to the conjoined tendon upward, the pubic symphysis inward, and the site 2 cm inferior to the pectineal ligament downward. A 12-×15-cm Vypro II mesh patch was placed at the preperitoneal space through the trocar with a diameter of 10 mm. Afterward the patch was fixed onto the Cooper ligament, endoabdominal fascia, and iliopubic tract using an endoscopic multifeed stapler (Ethicon). The peritoneal flap was sutured and then closed. Bilateral hernias were treated using the same procedure.

The TEP group

The TEP method proposed by McKernan and Laws⁵ was adopted, and the procedure was performed with the patient under tracheal intubation plus general intravenous anesthesia. The surgeon and the assistant both stood on the healthy side of the patient. The patient was placed a supine position with a higher head and lower feet between 15° and 30°. An incision of 1.2 cm in length was made at the site 1 cm inferior to the navel. The linea alba abdominus was cut open, and the rectus abdominis was subsequently pulled open to both sides to expose the posterior sheath of the rectus abdominis. Downward separation was done along the posterior sheath by blunt dissection. A trocar of 10 mm in diameter was inserted and connected to a CO₂ insufflator with the pressure maintained between 9 mm Hg and 12 mm Hg. A laparoscope was inserted. Under direct vision, two trocars with a diameter of 5 mm were inserted at the upper middle and lower middle one-third sites of the line between the umbilicus and the pubic bone. The areolar tissue of the preperitoneal space was isolated sharply to expose the pubic symphysis and pectineal ligament as well as the spermatic cord and hernia sac. The sac was dissected off the abdominal wall and completely separated from the spermatic cord. The spermatic cord was separated from the peritoneum and adhered closely to the muscular layer of the abdominal wall. The deferent duct, the blood vessels of the spermatic cord, and “danger triangle” were exposed. A 10-×15-cm Vypro II mesh patch was inserted and flattened to cover Hesselback's triangle, the endostoma of the indirect hernia, and the femoral canal. The mesh must overpass the pubic tubercle on the opposite side, and its lateral reached the anterior superior iliac spine. The mesh was not fixed. The inferior angles of the mesh were suppressed using Satinsky's clamps. Then, CO₂ was discharged under direct vision. The mesh must be flattened and adhered by the peritoneum. Bilateral hernias were treated using the method.

Postoperative treatment and observation indices

Intra- and postoperative routine fluid replacement and preoperatively preventive antibiotics were administered. The patients were given semifluid diet at 6 hours after return to consciousness from anesthesia. They began to eat regular food from Day 1 after the operation. The operating time, postoperative hospital stay, intra- and postoperative complications, postoperative pain scores, postoperative analgesic administration, postoperative local dysthesia, postoperative chronic pains, and postoperative long-term hernia relapse of different groups were observed and then compared. The postoperative pains were scored using a numerical rating scaling.

Statistical analysis

All data were presented as standard deviation and analyzed using SPSS version 17.0 software (SPSS, Inc., Chicago, IL). The paired t test was performed. Numeration data were tested using the chi-squared method. A value of P<.05 was considered statistically significant.

Results

All TAPP and TEP operations were completed smoothly, without intraoperative conversion to open surgery. The postoperative pain scores of the TAPP and TEP groups were 2.94±0.99 and 1.98±0.64, which were significantly better than that of the Lichtenstein group (4.25±0.46). In the LIHR groups, no postoperative hernia relapse occurred, which was also significantly better than the Lichtenstein group, in which 4 recurrent cases occurred (4.76%) (P=.017). The hospitalization costs of the TAPP and TEP groups were 9504±1132 RMB and 9351±985 RMB, which were significantly higher than that of the Lichtenstein group (5852±864 RMB) (P=.009), because of the use of a larger mesh and laparoscopic equipment. No significant differences among the operating tine, postoperative postoperative scrotal seroma, postoperative local esthesiodermia, and postoperative chronic pains of the LIHR and Lichtenstein groups were observed (P>.05). The occurrence rate of postoperative scrotal seroma or hydrops in the TAPP, TEP, and Lichtenstein groups was 11 (13.10%), 13 (15.48%), and 6 (7.14%), respectively. The patients were followed up from 3 months to 32 months with an average of 16 months, except that 3 patients in the TAPP group, 2 patients in the TEP group, and 4 patients in the Lichtenstein group were lost to follow-up. The results are summarized in Table 2.

Table 2.

Intra- and Postoperative Comparisons Among the Three Different Groups

Indices	Operating time (minutes)	Postoperative pain score	Postoperative scrotal seroma or hydrops	Postoperative local dysesthesia	Postoperative chronic pain	Postoperative hernia relapse	Cost of hospitalization (RMB)
TAPP (n=84)	47.22±16.59	2.94±0.99	11 (13.10%)	5 (5.95%)	0	0	9504±1132
TEP (n=84)	50.52±14.1	1.98±0.64^a	13 (15.48%)	4 (4.76%)	0	0	9351±985
Lichtenstein (n=84)	46.21±4.47	4.25±0.46^a,b	6 (7.14%)	12 (14.29%)^b	2 (2.38%)	4 (4.76%)^a,b	5852±864^a,b
Statistic	F=2.512	F=12.948	Chi-squared=2.951	Chi-squared=5.922	Chi-squared=24.032	Chi-squared=28.129	F=24.386
P value	.139	.016	.229	.052	.133	.017	.009

Data are mean±standard deviation values.

P<.05 compared with the transabdominal preperitoneal (TAPP) group.

P<.05 compared with the totally extraperitoneal (TEP) group.

Discussion

LIHR has the following advantages over the traditional tension-free repair:

1. It is an operation using “a posterior approach” in the real sense, in which the incision is distant from the region repaired with the mesh, thereby avoiding the risk of incision or mesh infection.

2. The procedure is performed posterior to the endo-abdominal fascia, and therefore the opening of the endo-abdominal fascia is not needed.

3. The operation is performed under laparoscopic direct vision of an amplifying power between 20 and 30, so therefore the visual field is distinct and the hernia as well as the anatomic structure of the preperitoneal space can be observed clearly.

4. The application of laparoscopic equipment makes the separation of the preperitoneal space and the flattening of the mesh easier, because of which the use of a specialized modeled patch becomes unnecessary, thus reducing patch expense.

5. LIHR allows patients to return to normal activities and work earlier.⁶

6. LIHR is advantageous in the treatment of bilateral and recurrent hernias.^7,8 For bilateral hernias, no additional incision is needed, and for recurrent hernia, an anterior approach can be avoided, thus simplifying the surgical procedure.

7. LIHR is of help for the detection of an insidious hernia on the opposite side.

8. The incision is small, meeting an esthetic requirement, and the postoperative pain is less.⁹

9. LIHR can provide a special visual angle, with the aid of which surgeons can observe the anatomic structure of the myopectineal orifice from the back to better understand the characteristics of preperitoneal repair as well as the main points in LIHR operation.

The present study shows that compared with the Lichtenstein method, LIHR has the virtues of a smaller incision, a lessened postoperative pain, reduced postoperative analgesic administration, advanced postoperative out-of-bed activities, and hypostatic pneumonia caused by long-term bed rest. Furthermore, LIHR does not prolong operating time but does bring about a significantly better effect on long-term hernia recurrence. This effect may be correlated with a larger mesh used in LIHR.

This study also showed high incidences of seroma in the LIHR groups (13.10% in the TAPP group and 15.48% in the TEP group). Seroma is a common post-LIHR complication, which has an incidence between 1.9% and 22.9%.¹⁰ This complication is mainly caused by the secretions of the excluded distal hernia sac after hernia sac transection or the residual accumulated liquid in the empty cavity after hernia content reduction. Seroma has a high incidence among patients with a long-term adhesive hernia sac as well as with a large scrotal hernia. For patients with an indirect hernia, total dissection of the sac can reduce the incidence of seroma, but for patients with an adhesively compacted hernia sac, such a treatment will not be of much help because it is very likely to induce the occurrence of hematoma. Therefore, in the treatment of a hernia sac with a too large a volume, to amputate the sac with part of it remaining will be more advisable. Seroma is normally presented as clear pale-yellow fluid, which can begin self absorption from 1 week after operation and go away within 1–2 months.¹¹ To accelerate self-absorption, patients can be instructed to take hot compress every day; if the fluid persists, patients can receive puncture aspiration, leaving surgical intervention only in special circumstances.¹² Hematoma refers to congestion masses in the inguinal region or in the scrotum. Postoperative hematoma is mainly caused by intraoperative vascular injury and imprecise hemostasis. This condition can also occur among the elderly as a consequence of blood oozing from the wound surface due to a high vascular fragility. As hematoma is characterized by dense masses in most circumstances, a combined modality therapy in the department of physiotherapy is recommended instead of a puncture, whereas pressed drainage is not recommended in case of infections unless in special circumstances. Furthermore, attention should be paid to the distinction between hematoma and hernia recurrence to avoid an unnecessary operation (this can be done using B-scan ultrasonography).

Tension-free hernia repair can give rise to a recurrence rate of primary hernias of only 0.1% and that of recurrent hernias of 2%.¹³ Post-LIHR hernia recurrence has two features: one is that the recurrence rate was high at an early development stage of LIHR, showing a correlation with the learning curve, and the other is that more recurrent hernias are seen at the early stage (between 3 and 6 months) after LIHR, which is inconsistent to the distribution features of recurrent hernias treated with traditional surgery. These features suggest that post-LIHR hernia recurrence is mainly caused by operative lapses. A standardized surgical procedure can reduce the recurrence rate. The standardization can include two respects as follows:

1. A sizeable patch of mesh, for a mesh with a too small size is always an important factor of hernia recurrence. The recurrence rate after the use of 8-×8-cm and 12-×12-cm meshes is 3.8%, whereas that after the use of 10-×10-cm and 15-×15-cm meshes is only 0.2%.¹⁴ The respective replacement of 6-×6-cm and 11-×11-cm meshes by 10-×10-cm and 15-×15-cm meshes reduces the hernia recurrence rate from 5% to 0.16%.¹⁵ To avoid hernia recurrence and reappearance, the mesh in use must be large enough to cover the myopectineal orifice and overlap somewhat with the surrounding muscular or osseous tissues. Specifically, the inside margin of the patch should overpass the opposite pubic tubercule, its outside margin should reach the anterosuperior iliac spine, its superior margin should have an overlap of no less than 2 cm with the conjoined tendon, and the inner side of the inferior margin should be placed in the interspace between the pubic bone and the bladder and the outer side no less than 6 cm distant from the inner ring. Therefore, 10-×10-cm and 15-×15-cm patches are the advisable options in normal conditions.

2. Reasonable patch fixation. A patch can be fixed using a hernia fixator, saturating, or fibrin glue.¹⁶ The fixation points can include the outer margin of the rectus abdominis, the periosteum of the pubic tubercle, the pectineal ligament, and the conjoined tendon, but not other places. Otherwise, complications such as hemorrhage and neuralgia can be induced. In patch fixation, the coverage of the patch over the pubic tubercule and its fixation there are most important because most recurrent hernias occur in Hesselback's triangle beside the pubic tubercule.¹⁷ In the operation, the patch is normally tiled on the spermatic cord and flattened as much as possible because a curled patch tends to induce postoperative hernia recurrence. However, the patch in LIHR is not necessarily fixed. In recent years, many studies have reported surgical procedures in which patch fixation is not involved. According to them, whether the patch should be fixed or not depends on the type of a hernia rather than the type of a patch. For hernias of less than 4 cm, patch fixation may not be performed.¹⁸ Patch fixation is only necessary for bilateral hernia.

However, this study showed that the costs in both the TEP and the TAPP groups were significantly higher than that in the Lichtenstein group. As laparoscopic equipment is necessary in the LIHR procedure, equipped hospitals therefore should take full advantage of current resources to avoid an extra cost. Meanwhile, LIHR does not require other consumable materials except for patches; thus, repeatable laparoscopic equipment can be used to replace disposable equipment in order to reduce medical costs. At the early stage of LIHR development, patch fixation using a hernia fixator or biological glue was always needed. However, according to recent reports, this fixation is not necessarily needed for hernias of less than 4 cm, which can obviously reduce the medical expense of LIHR. Furthermore, even for hernias of more than 4 cm, patch fixation can be done using suturing instead of stapling, which can also greatly reduce the required expense.

In summary, laparoscopically equipped hospitals can deliver LIHR treatment for patients with a hernia. Although LIHR increases treatment expense because of the application of laparoscopy as well as of the corresponding anesthetic method, it has the virtues of faster postoperative recovery, a wider repaired range, and a better repair effect, compared with the traditional surgery procedure. Meanwhile, the increased treatment expense is often acceptable to most patients. Furthermore, the posterior approach used in LIHR is more in line with the principle of mechanics. Therefore, it is reasonable to believe that with the development of laparoscopy, the application of LIHR in repairing hernia will be more and more widely accepted.

Footnotes

Disclosure Statement

No competing financial interests exist.

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