Laparoscopic Total Extraperitoneal Groin Hernia Repair in Females: Comparison of Outcomes Between Preservation or Division of the Uterine Round Ligament

Introduction

Groin hernias occur less commonly in women, accounting for 8% of groin hernia repairs in the Swedish Hernia Registry. ¹ The HerniaSurge Group has published international guidelines on management of groin hernias in 2018, recommending laparoendoscopic mesh repair as the method-of-choice in women if expertise is available. ²

In contrast to open approach, laparoscopic repair in women has been shown to have a lower rate of recurrence.^1,3–5 Specifically upon comparison of laparoscopic approach with Lichtenstein repair, data from the Danish Hernia Database demonstrated a hazard ratio of 0.57 for recurrence with the former approach, ⁴ whereas data from the Swedish Hernia Registry similarly revealed a relative risk of 0.4 for reoperation for recurrence after laparoscopic repair. ¹ Among reoperations for recurrences after female groin hernia repair, up to 50% were reported to be femoral hernias. ¹ The femoral space may not be routinely explored during open repair hence, femoral hernias may be overlooked upon primary repair, whereas laparoscopic repair gives a clear view of the femoral space allowing incidental femoral hernias to be detected and repaired.^2,6

With regard to the technical aspect of laparoscopic repair among women, controversy exists as to whether the round ligament of uterus could be divided to facilitate mesh placement. Anatomically, nerves travel with the round ligament upon entering the deep inguinal ring, hence its division proximally should not confer nerve injury. ² However, the round ligament may help to maintain the uterus in an anteverted position, raising the concern of possible genitourinary complications associated with its division. ⁷ Surgeons have different opinions on the potential consequences after transection of the ligament, ⁸ for which there is limited evidence currently.

This study aims to review the outcomes of laparoscopic total extraperitoneal (TEP) groin hernia repair in women and to evaluate the clinical impact of division of round ligament.

Methods

Data from consecutive female patients who underwent elective laparoscopic TEP groin hernia repair at Tung Wah Hospital, Hong Kong, from 2006 to 2017 were retrospectively reviewed. For patients presenting with groin hernia, TEP was offered if they were fit for general anesthesia, with no history of major abdominal surgery and were nonobese. Patients presenting with incarcerated or strangulated hernias were excluded.

TEP was performed by experienced surgeons. Patients were operated on while placed in a supine Trendelenburg position. A three-port technique was used. The camera port (10 mm) was created at subumbilical region by open method. Carbon dioxide was insufflated to a pressure of 10 mmHg. The preperitoneal space was created by using a telescope. A 5-mm trocar was inserted at midline 8 cm proximal to pubic symphysis under laparoscopic view. The dissection of the extraperitoneal space was performed with endoscissors and diathermy under the view of a 30° telescope. A second 5-mm port at midline 3 cm from pubic symphysis was inserted under laparoscopic view. Alternatively, the second 5 mm port was inserted 3 cm proximal to anterior superior iliac spine after incising the arcuate ligament. Hernia sac was dissected. The round ligament was either preserved or transected together with the indirect sac according to surgeon's preference (Fig. 1). A lightweight mesh was then inserted, covering the deep inguinal ring, the femoral ring, and direct defect (if any). The mesh may be fixed with tackers or fibrin glue. Mesh position was checked upon deflation of the preperitoneal space.

OPEN IN VIEWER

FIG. 1.

Relationship of indirect inguinal hernia sac with round ligament in right groin total extraperitoneal repair.

The postoperative analgesic regimen included etoricoxib 120 mg daily for 3 days and paracetamol 500 mg four times daily for one week. Patients had clinic follow-ups at 2-week, 3-month, 6-month, and 1-year intervals, followed by yearly follow-up. Any complications including seroma, wound infection, and recurrence were recorded. Postoperative pain and paresthesia were assessed. Chronic pain was defined as the presence of pain at the groin area at rest 3 months after surgery. Patients who visited gynecologists and diagnosed with genital prolapse were recorded.

Statistical analysis was performed with SPSS 20.0 (IBM Corp., Armonk, NY). Categorical variables were analyzed with chi-square test, whereas continuous variables were analyzed with Mann–Whitney U-test. Logistic regression was performed for multivariable adjusted analysis of outcomes associated with division and preservation of round ligament. A P value of <.05 was considered statistically significant.

Results

During the 12-year study period, 156 female patients underwent groin hernia repair in our center, among which 68 (43.6%) were performed with laparoscopic TEP approach and were included in this study. Nine patients underwent bilateral TEP, accounting for a total of 77 repairs performed. The mean age at hernia repair was 45 ± 16 years old. Patient characteristics and operative findings are listed in Table 1. The most common hernia type was indirect inguinal hernia accounting for 83.1%, whereas direct inguinal hernia and femoral hernia accounted for 7.8% and 2.6%, respectively. Incidental femoral hernia was identified and repaired in 4 patients (5.9%). The round ligament was divided in 67.5% of patients as documented in the operative record. The mean operation time was 58 ± 22 minutes. The median length of postoperative hospital stay was 1 (range 0–2) day and 27 patients (39.7%) underwent TEP as day surgery.

For postoperative complications (Table 2), seroma occurred after eight (10.4%) repairs, whereas wound infection occurred in one (1.3%). There were no mesh complications. Apart from 13 patients lost to follow-up, the mean follow-up time was 42.9 ± 37.3 months. In total, 19.5% of patients reported to have persistent groin pain beyond 3 months, whereas 7.8% had persistent paresthesia. There was one (1.3%) recurrence 10 years after TEP for indirect inguinal hernia, presenting with incarceration, requiring emergency repair. Genital prolapse occurred in 4 patients (5.9%), 3 of them had the round ligament preserved.

Furthermore, outcomes of patients with division of round ligament were compared with those with preserved round ligament. Characteristics of these two groups are reported in Table 3. Only differences in the mean age (42 versus 54 years old, P = .005) and mean length of postoperative hospital stay (0.71 versus 1.2 days, P = .013) were statistically significant. Operation time of the two groups was comparable (57 versus 64 minutes, P = .183). Upon multivariable adjusted analysis, there were no statistically significant differences in terms of chronic pain (odds ratio [OR] = 2.210, P = .357), paresthesia (OR = 0.241, P = .149), and genital prolapse (OR = 0.327, P = .415) between the two groups (Table 4). Three out of the 9 patients with bilateral TEP had round ligaments of both sides divided and none of them developed genital prolapse.

Five patients had subsequent pregnancies after operation. There were no groin complications or increase in groin pain reported during pregnancy or delivery.

Discussion

Female groin hernias occur less commonly than men and laparoscopic approach has been recommended as the method of repair if expertise is available. ² Outcomes of our cohort were comparable with current literature: 1.3% recurrence rate that was similar to that reported in other studies being 1.4%–1.8%.^3,5 Femoral hernias were detected incidentally and repaired in 5.9% of our patients, compatible with another study demonstrating that femoral hernia is the most common type of incidental hernia detected in TEP repair. ⁹ This illustrated the advantage of laparoscopic repair in allowing visualization and mesh coverage of the femoral space, which prevents overlooking of femoral hernia in the primary operation and minimizes the risk of femoral recurrence.

For postoperative pain, 19.5% of our patients reported to have some degree of groin pain beyond 3 months, with most of them grading the pain to be mild in severity. No patient complained of severe pain and none required referral to pain clinic. There was a higher incidence of chronic pain in patients who had the round ligament divided compared with those with the round ligament preserved (26.5% versus 9.5%, P = .112), yet upon adjusted analysis, it was not statistically significant. During surgery, care has been taken to avoid injury to the femoral nerve, femoral branch of genitofemoral nerve, and lateral femoral cutaneous nerve located within the triangle of pain below the iliopubic tract. ¹⁰ In cases wherein tackers were used for mesh fixation, they were avoided within this area. Nevertheless, female gender has been identified as a risk factor for acute and chronic pain after hernia surgery.^11–13 Specifically among women, results from studies comparing the incidence of postoperative pain after laparoscopic and open repair were controversial. A study reported 6.4% of female patients undergoing TEP repair complaining of moderate-to-severe persistent pain, significantly lower than the group undergoing open repair being 21.7%. ³ In contrast, other studies showed no statistically significant difference in postoperative pain when comparing women undergoing laparoscopic repair and those undergoing open repair.^6,14

On a technical aspect, there has been limited evidence addressing whether the round ligament of uterus should be divided during laparoscopic repair. Theoretical concern on potential genitourinary complications after ligament transection has been raised as the round ligament normally maintains the uterus in an anteverted position. ⁷ A survey involving Danish surgeons who regularly perform laparoscopic groin hernia repair demonstrated varied views on the role of round ligament and whether it could be transected, giving an estimate of 49% of laparoscopic repairs having the round ligament divided. ⁸ Techniques in preservation of the round ligament with the use of a slit mesh have also been described in the literature. ¹⁵ With the data from the Danish Hernia Database comparing women with open repair versus those with laparoscopic repair and based on the assumption that the round ligament was more commonly divided in laparoscopic repair, it has been suggested that the genitourinary consequences associated with division of the round ligament were minimal. ⁷

In our center, TEP is the predominant type of laparoscopic hernia repair. There is no consensus on the technique in female TEP as already mentioned, therefore, the management of round ligament is dependent on individual surgeon preference. For surgeons who favor division of the round ligament, the main concern is peritoneal injury during dissection of the indirect sac from the round ligament, which is not uncommon as they are densely adhered in most cases. If the sac and round ligament are isolated and transected together, the risk of peritoneal injury is minimized. Peritoneal perforation leads to decrease in working space and is not favorable in TEP. In addition, the round ligament may lead to lifting of mesh and this may potentially increase the risk of recurrence. As recommended in the guidelines by the HerniaSurge Group, division of the round ligament is optional and it should be transected proximal to its meeting with the genital branch of the genitofemoral nerve at the deep inguinal ring, which is best formed at the fusion with the peritoneum where division has no functional implication. ² On the contrary, for some surgeons worried about potential gynecological complications after the transection of round ligament, in that case only the hernial sac is dissected and the round ligament was preserved.

In our study, comparison of outcomes between the groups with round ligament division and preservation showed no statistically significant differences in chronic pain, paresthesia, and genital prolapse upon adjusted analysis, suggesting minimal consequences with transection of round ligament. Moreover, as mesh placement becomes easier with the ligament transected, the operative time may also be shortened despite the difference being statistically insignificant in our cohort (56 versus 63 minutes, P = .109). For the difference in mean age between the two groups (42 versus 54 years old, P = .005), it was largely by coincidence. There was no intention to preserve the round ligament in older patients.

The retrospective nature of this study was one of its limitations. TEP may not be suitable for every hernia patient and surgeons decide which approach is best for individual patient, therefore selection bias is present. TEP only accounted for 43.6% of all groin hernia repairs in the 12-year study period, as a result the studied population is small; any small differences in outcomes between the groups with transection or preservation of round ligament may not achieve statistical significance with our sample size. Multicenter studies may be necessary to achieve a large sample size. In addition, the cause of genital prolapse is multifactorial; other contributing risk factors such as multiparity have not been included in the analysis, therefore, it is difficult to determine its correlation with surgery. Despite the limitations, this study provided insights into the clinical outcomes of female patients who underwent TEP with different techniques, which has not been addressed in previous studies.

Conclusions

Laparoscopic TEP groin hernia repair in women is associated with low morbidity and low recurrence rates. Division of round ligament intraoperatively facilitates mesh placement and has minimal impact on outcomes in terms of chronic pain, paresthesia, and genital prolapse.