Evaluation of the Factors Influencing on Intraoperative Difficulty Scores of Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair

Abstract

Background:

Inguinal hernias are the leading surgical diseases in the world. There are different surgical procedures reported for the treatment. Some problems are thought to be encountered when performing laparoscopic surgery in these patients, such as risk of severe complications and the prolonged operative duration.

Aim:

The objective of this study was to specify the complexity of the transabdominal preperitoneal (TAPP) procedure by using an intraoperative scoring system and examine the scores with these patients' predictive factors.

Materials and Methods:

A prospective study was conducted in patients who underwent inguinal hernia surgery with TAPP. Previous lower abdominal surgery, previous (open) hernia surgery, body mass index (BMI), type of hernia, duration of the surgery, scoring the difficulty of the operation in five various stages using the visual analog scale (VAS) score (1. Mobilizing the peritoneum/dissection of the inferior peritoneal flap. 2. Dissection of internal ring or vas deference or hernia sac. 3. Visualization of Cooper's ligament. 4. Mesh placement. 5. Peritoneal closure.) and the time of discharge were recorded.

Results:

In this study, 137 patients were included. “BMI” and “previous lower abdominal surgery” have significantly higher scores, time of surgery, and hospital stay compared with other risk factors (P < .005).

Conclusion:

Introduction

Inguinal hernias are one of the most frequently encountered surgical diseases in the world. Although not all patients require surgery, inguinal hernia symptoms may develop over time in the vast majority of patients and may require surgical intervention.¹ There are types of accepted inguinal hernia surgical procedures and each of these procedures has its own advantages and difficulties.²

Transabdominal preperitoneal (TAPP) inguinal hernia repair has its origins in the early 1990s. The technique of preperitoneal reinforcement of the myopectineal orifice using a prosthetic mesh was developed by Rives and Stoppa. In the mid-90s, researchers began publishing their study on TAPP repair. Open anterior repairs are recommended for patients with a history of repairs using the preperitoneal space, prostatectomy, anterior spinal surgery, prior significant trauma of the pelvis, or cystectomy as in these patients, the preperitoneal plane is often obliterated.

Therefore, the choice of surgery for inguinal hernia patients in patients with previous lower abdominal surgery or obesity is controversial, and the presence of adhesions in the prevesical space is thought to mean that open surgery is widely used even in institutions where laparoscopic surgery is performed as a standard technique. Some challenges are thought to be confronted when performing laparoscopic surgery in these patients, such as risk of severe complications and the prolonged operative duration.^3–6

Although TAPP is a safe, effective, and widely performed technique, it has its own technical details and challenges that need attention. These technical steps are; mobilizing the peritoneum, dissection of the inferior peritoneal flap, dissection of the internal ring/vas deference or hernia sac, visualization of Cooper's ligament, mesh placement, and peritoneal closure.⁷ It is not always possible for us to predict the complexity of the surgery before the operation. Several preoperative difficulty criteria have been reported in some studies. However, there is no classification and evaluation of intraoperative findings determined in laparoscopic hernia surgery.

The objective of this study was to examine the effects and results of some predictive factors in patients on the difficulty of TAPP surgery using an intraoperative scoring system.

Materials and Methods

In total, 137 patients who had elective unilateral inguinal hernia TAPP surgery between January 2018 and July 2021 were included in this study. Patients with femoral, ventral/incisional or bilateral inguinal hernia, previous endoscopic/laparoscopic inguinal hernia surgery, and urgent hernia surgery were excluded from the study. The prospective study protocol was approved by the local ethics committee of Bursa Yüksek İhtisas Training and Research Hospital (25 2021/09–16). Informed consent form was signed by all patients.

All the operations were scored by an experienced surgeon who was not attending the operation. Medical files of patients were analyzed in terms of body mass index (BMI), previous lower abdominal surgery, previous (open) hernia surgery, type of hernia, operation time, length of hospital stay, and complications.

The surgeon who did not participate in the procedure was in charge of scoring all steps of the operations according to the degree of difficulty. The experienced surgeon scored the complexity of the procedure in five different stages: (1) Mobilizing the peritoneum/dissection of the inferior peritoneal flap (finding the proper layer, maintaining the proper layer dissection, the need for excess traction during dissection). (2) Dissection of internal ring or vas deference or hernia sac (recognizing and dissecting vessels and spermatic cord safely, requiring hemostatic procedures for bleeding, and reducing the hernia sac properly and completely). (3) Visualization of Cooper's ligament (visualizing anatomic landmarks clearly, ensuring adequate extension of dissection area). (4) Mesh placement (placing, mobilizing, and fixing the mesh properly). (5) Peritoneal closure (smooth needle movement, tear in the peritoneum, visibility of the mesh from the suture line).

The difficulty level of the surgery was noted using the visual analog scale (VAS) score raging from 1 through 10. VAS scores are used to quantify particular clinical phenomena but especially when trying to accurately record subjective measurements. VAS has been used in some studies to determine the degree of difficulty for different types of surgeries.^8–10

Statistical analysis

NCSS (Number Cruncher Statistical System) 2007 Statistical Software (Utah, USA) package program was performed for statistical analyses. In addition to descriptive statistical methods (mean, standard deviation), chi-square test for comparisons of qualitative data, one-way analysis of variance was used for intergroup comparisons, independent t-test for pairwise comparisons, and Tukey multiple comparison test for subgroup analysis. P values < .05 were considered statistically significant.

Results

Adequate data were obtained from 137 of 155 patients determined by study period. Open surgery conversion was required in 3 patients due to diffuse adhesions, who were excluded from the study (Table 1). In total, 70.1% (n = 96) of the patients were male and mean age was found as 47.64 ± 14.23 (18–77) years. Patients with the history of lower abdominal surgery (C/S, incisional hernia, prostatectomy, etc.) (n = 31; 22.6%) had significantly higher scores in the inferior peritoneal flap dissection (P = .0001), visualization of Cooper's ligament (P = .0001), mesh placement (P = .002), and peritoneal closure (P = .0001).

Table 1.

Distribution of Patient Demographics and Predictive Factors Affecting Difficulty of Transabdominal Preperitoneal Procedure

Parameter	N = 137		Range/percentage (%)
Age	47.64 ± 14.23		18–77 years
Gender	Female	41	29.9
Gender	Male	96	70.1
BMI (kg/m²)	<30	101	73.7
BMI (kg/m²)	≥30	36	26.3
Previous hernia surgery	Yes	26	18.9
Previous hernia surgery	No	111	81.1
Previous lower abdominal surgery	Yes	31	22.6
Previous lower abdominal surgery	No	106	77.4
Hernia type	Direct	60	43.8
Hernia type	Indirect/mix	77	56.2

BMI, body mass index.

Duration of surgery (P = .0001) and length of stay (P = .003) were also significantly higher in this group, but dissection of internal ring/hernia sac score was not significantly different (P = .169; Table 2). Obese patients (BMI ≥30 kg/m²; n = 36) had significantly higher scores in dissection of the inferior peritoneal flap (P = .004), dissection of internal ring/hernia sac (P = .041), and visualization of Cooper's ligament (P = .007), but mesh placement score (P = .371) and peritoneal closure score (P = .981) were not significantly different. Duration of the operation (P = .001) and length of stay in the hospital (P = .001) were significantly higher in patients with higher BMI (Table 3).

Table 2.

Effects of “Previous Lower Abdominal Surgery” on Difficulty Scores

	Surgery (−)	Surgery (+)	P
Mobilizing the peritoneum/dissection of the inferior peritoneal flap	2.81 ± 1.98	4.21 ± 2.88	.0001
Dissection of internal ring/vas deference/hernia sac	2.3 ± 1.56	2.59 ± 1.68	.169
Visualization of Cooper's ligament	3.21 ± 1.46	5.34 ± 2.49	.0001
Mesh placement	2.81 ± 2.1	3.89 ± 2.57	.002
Peritoneal closure	3.29 ± 1.66	5.34 ± 2.69	.0001
Hospital stay (hours)	28.46 ± 13.45	34.2 ± 17.26	.003
Operation time (minutes)	27.51 ± 14.27	49.77 ± 22.05	.0001

Table 3.

Effects of “Body Mass Index” on Difficulty Scores

	BMI <30 kg/m² (n: 101)	BMI ≥30 kg/m² (n: 36)	P
Mobilizing the peritoneum/dissection of the inferior peritoneal flap	3.75 ± 2.19	5.75 ± 3.38	.004
Dissection of internal ring/vas deference/hernia sac	3.85 ± 2.36	5.22 ± 3.43	.041
Visualization of Cooper's ligament	3.15 ± 2.22	5.11 ± 3.5	.007
Mesh placement	2.34 ± 1.65	2.79 ± 2.44	.371
Peritoneal closure	3.2 ± 2.14	3.22 ± 2.31	.981
Hospital stay (hours)	28.44 ± 14.26	44.55 ± 24.3	.001
Operation time (minutes)	34.39 ± 16.51	52.25 ± 32.66	.001

BMI, body mass index.

History of hernia surgery increased only dissection of internal ring/hernia sac score significantly (P = .024), but dissection of inferior flap score (P = .306), visualization of Cooper's ligament score (P = .238), mesh placement score (P = .859), and peritoneal closure score (P = .977) were not statistically significant. There was no significant difference in the length of hospital stay (P = .076) and operation time (P = .076; Table 4). In our study, patients with indirect/mix hernia had significantly higher score in dissection of internal ring/hernia sac (P = .0001). Other scores, duration of operation, and hospital stay were not significantly different compared with those of patients with direct hernia (Table 5).

Table 4.

Effects of “Previous Hernia Surgery” on Difficulty Scores

	Hernia surgery	No hernia surgery	P
Mobilizing the peritoneum/dissection of the inferior peritoneal flap	2.58 ± 1.56	2.32 ± 1.68	.306
Dissection of internal ring/vas deference/hernia sac	4.21 ± 2.39	3.42 ± 1.79	.024
Visualization of Cooper's ligament	3.34 ± 2.29	2.99 ± 2.12	.238
Mesh placement	3.21 ± 2.22	3.18 ± 1.98	.859
Peritoneal closure	2.35 ± 1.53	2.39 ± 1.99	.977
Hospital stay (hours)	28.11 ± 16.31	23.36 ± 6.88	.076
Operation time (minutes)	37.15 ± 14.29	36.42 ± 13.1	.812

Table 5.

Effects of “Hernia Type” on Difficulty Scores

	Indirect/mix	Direct	P
Mobilizing the peritoneum/dissection of the inferior peritoneal flap	3.66 ± 1.44	3.47 ± 1.37	.304
Dissection of internal ring/vas deference/hernia sac	5.12 ± 2.39	3.36 ± 2.25	.0001
Visualization of Cooper's ligament	3.18 ± 2.27	3.16 ± 2.15	.926
Mesh placement	2.63 ± 1.62	2.28 ± 1.73	.315
Peritoneal closure	3.18 ± 2.25	3.13 ± 1.92	.861
Hospital stay (hours)	24.11 ± 10.16	21.3 ± 11.7	.376
Operation time (minutes)	38.4 ± 15.2	35.1 ± 15.5	.439

Discussion

Although inguinal hernia repair has been described with different techniques over the years, there is no definite conclusion about which surgical approach is superior to the others. In recent times, laparoscopic inguinal hernia repair is performed more frequently in clinics due to the development of laparoscopic tools and surgical techniques.^11–13 Laparoscopic/endoscopic inguinal hernia repair techniques are mainly specified as TAPP and totally extra peritoneal (TEP). In the literature, in clinical studies on TEP and TAPP, each technique has its own positive and negative sides, but there are no significant differences in the results showing superiority.

For this reason, according to the guidelines, it is recommended that surgeons use the laparoscopic technique with which they are most prone and experienced.^14,15 The learning curve for TAPP is longer because of the major sophistication of the procedure. In studies of laparoscopic repairs, inguinal hernia, postoperative pain, and the incidence of recurrence were significantly higher in low experienced (<25 procedures/year) surgeons.¹⁶

During laparoscopic hernia repair, technically challenging situations such as uncontrolled bleeding, unidentified anatomical structures, demanding peritoneal dissection, and adhesions can be experienced. In such conditions, the operation time is usually prolonged or perioperative major complications may occur. For this reason, especially surgeons with less experience should carefully select the suitable candidates they want to operate with the laparoscopic technique before the operation.

Scoring and grading of surgical conditions provide us with a convenient tool for reporting disease severity. An accepted objective scoring system that predicts the difficulty of laparoscopic inguinal hernia repair has not been defined in the studies. In our study, we scored the operation in five stages and aimed to identify the risk factors affecting the TAPP difficulty of the patients preoperatively. Risk factors are determined as history of lower abdominal surgery, previous open hernia surgery, BMI, and hernia type.

There are studies suggesting a history of lower abdominal surgery as a risk factor for the TAPP procedure.¹⁷ In previous studies, the laparoendoscopic approach was considered to be contraindicated because of the possibility of adhesions and the risk of bladder injury after open prostatectomy.

Wauschkuhn et al evaluated TAPP results in 264 patients who underwent inguinal hernia repair with a history of radical prostatectomy surgery. They analyzed that the operation time was longer and the complication rate was higher in the group with a history of prostatectomy than those in the primary case group. Furthermore, they reported that no statistical difference was observed in the recurrence rate. In our study, all scores of the difficulty, hospital stay, and duration of the operation were statistically significant in patients with the previous lower abdominal surgery than in others, except score of dissection of internal ring/hernia sac (0.169).¹⁸

In the studies, the patient's history of open hernia surgery was not included as a difficulty factor. However, in recurrent hernia surgeries after open hernia repair, patients with open hernia repair have more postoperative pain and slower recovery than patients undergoing endoscopic inguinal hernia repair techniques.¹⁹ In our study, patients with the history of hernia surgery had significantly higher score only in dissection of internal ring/hernia sac (0.024).

Kato et al reported a significant relationship between longer operation time and BMI (TEP procedure) and they suggested that surgery in patients with obesity may be more challenging not only because of anatomical factors, but also because of obesity-related comorbidities.²⁰

We noted that the higher BMI group had a significantly higher difficulty scores of mobilizing the peritoneum/dissection of the inferior peritoneal flap (0.004), dissection of internal ring/hernia sac (0.041), visualization of Cooper's ligament (0.007), and statistically higher hospital stay (0.001) and operation time (0.001).

Type of the inguinal hernia is not described as a technically challenging situation during laparoscopic hernia repair. There is no comparative study for TEP or TAPP regarding this situation in the literature. In our study, patients with indirect or mix type hernia had significantly higher difficulty scores only in dissection of internal ring/hernia sac (0.0001).

Conclusion

This study showed that patient's BMI and previous lower abdominal surgery could create technical difficulty with the TAPP procedure, but it is not necessary to avoid this laparoscopic technique because of these situations and can be performed safely. Therefore, BMI and previous lower abdominal surgery could be the factors to consider for patient selection, especially in surgeons on the learning curve for the TAPP surgery. In patients with the aforementioned difficulties, surgeons in the learning period may prefer open surgery, since there is no difference in terms of recurrence with the TAPP procedure in the studies.

In further studies, the difficulty scores of these patients can be compared with those of the robotic hernia repair technique in experienced clinics. This scoring system can be encouraging for the start of laparoendoscopic hernia repair surgery and can help in choosing the right patient. Furthermore, larger studies need to be conducted for determining the effectiveness of the scoring system we have established.

Footnotes

Acknowledgments

The author thanks all the surgeons who assisted in this study.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

Fitzgibbons Jr

, Ramanan

, Arya

, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg, 2013; 258,(3):508–515; doi: 10.1097/SLA.0b013e3182a19725.

Rutkow Ira

. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am, 2003; 83,(5):1045–1051; doi: 10.1016/S0039-6109(03)00132-4.

Stoppa René E, Rives JL, Warlaumont CR, et al. The use of Dacron in the repair of hernias of the groin. Surg Clin North Am, 1984; 64,(2):269–285; doi: 10.1016/s0039-6109(16)43284-6.

Arregui Maurice

, Davis

, Yucel

, et al. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: A preliminary report. Surg Laparosc Endosc, 1992; 2(1):53–58.

Litwin Demetrius

, Pham

, Oleniuk

, et al. Symposium on the management of inguinal hernias, 3: Laparosopic groin hernia surgery: The TAPP procedure. Transabdominal preperitoneal repair. Can J Surg, 1997; 40(3):192.

Ohuchi

, Fukunaga

, Nagakari

, et al. Surgical technique and outcomes of transabdominal preperitoneal inguinal hernia repair after radical prostatectomy: Dissection between the transversalis fascia and superficial layers of preperitoneal fascia. Hernia, 2019; 23,(1):167–174; doi: 10.1007/s10029-018-1800-6.

Greenberg Jacob

Laparoscopic TAPP Repair. In: Hope WW, Cobb WS, Adrales GL (eds). Textbook of Hernia. Springer, Cham; 2017; pp. 91–97.

Veenhof

, Engel

, Van Der Peet

, et al. Technical difficulty grade score for the laparoscopic approach of rectal cancer. Int J Colorectal Dis, 2008; 23,(5):469–475; doi: 10.1007/s00384-007-0433-5.

Coats

, Carden

, Zujovic

, et al. Qualifying the difficulty of embryo transfer with a visual analogue scale and assessing its impact on IVF outcomes. Hum Fertil (Camb), 2019; 22,(3):177–181; doi: 10.1080/14647273.2018.1434903.

10.

Sánchez-Torres

, Mota

, Cle-Ovejero

, et al. Does mandibular gonial angle predict difficulty of mandibular third molar removal?. J Oral Maxillofac Surg, 2019; 77,(9):1745–1751; doi: 10.1016/j.joms.2019.04.002.

11.

Putnis

, Christophe

. Totally extraperitoneal repair of inguinal hernia: Techniques and pitfalls of a challenging procedure. Langenbecks Arch Surg, 2012; 397,(8):1343–1351; doi: 10.1007/s00423-012-0999-4.

12.

Mccormack

, Scott

, Go

, et al. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev, 2003; 2003(1):CD001785; doi: 10.1002/14651858.CD001785.

13.

, Wang

, Feng

, et al. Comparison of open and laparoscopic preperitoneal repair of groin hernia. Surg Endosc, 2013; 27,(12):4702–4710; doi: 10.1007/s00464-013-3118-x.

14.

Bittner

, Arregui

, Bisgaard

, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc, 2011; 25,(9):2773–2843; doi: 10.1007/s00464-011-1799-6.

15.

Köckerling

, Bittner

, Jacob

, et al. TEP versus TAPP: Comparison of the perioperative outcome in 17,587 patients with a primary unilateral inguinal hernia. Surg Endosc, 2015; 29,(12):3750–3760; doi: 10.1007/s00464-015-4150-9.

16.

Köckerling

, Bittner

, Kraft

, et al. Does surgeon volume matter in the outcome of endoscopic inguinal hernia repair?. Surg Endosc, 2017; 31,(2):573–585; doi: 10.1007/s00464-016-5001-z.

17.

Muschalla

, Jochen

, Reinhard

. Effectivity of laparoscopic inguinal hernia repair (TAPP) in daily clinical practice: Early and long-term result. Surg Endosc, 2016; 30,(11):4985–4994; doi: 10.1007/s00464-016-4843-8.

18.

Wauschkuhn

, Jochen

, Reinhard

. Laparoscopic transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: Is it safe? Results of prospectively collected data of more than 200 cases. Surg Endosc, 2009; 23,(5):973–977; doi: 10.1007/s00464-008-0291-4.

19.

Simons

, Aufenacker

, Bay-Nielsen

, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia, 2009; 13,(4):343–403; doi: 10.1007/s10029-009-0529-7.

20.

Kato

, Iuamoto

, Suguita

, et al. Impact of obesity and surgical skills in laparoscopic totally extraperitoneal hernioplasty. Arq Bras Cir Dig, 2017; 30,(3):169–172; doi: 10.1590/0102-6720201700030002.