Does Prior Lower Abdominal Surgery Prevent Laparoscopic Hernia Repair (Totally Extraperitoneal or Transabdominal Preperitoneal)? A Prospective Observational Study

Introduction

The most widely used laparoscopic techniques for inguinal hernia repair are transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs. TAPP involves creating a small incision in the abdominal wall to enter the peritoneal cavity and the surgeon places a mesh behind the hernia defect through direct visualization of the hernia sac and surrounding structures, while in the TEP method, the peritoneal cavity is not entered and is performed completely outside the peritoneum, and the fact that the surgeon performs the repair in the space between the peritoneum and the abdominal wall provides some advantages in terms of postoperative pain and recovery. Both minimally invasive techniques have been shown to have lower complication rates and faster recovery times.

Ultimately, the choice between TAPP and TEP will depend on the specific characteristics of the hernia, the surgeon’s experience and preference, and the patient’s individual factors.

Here, we operated on a total of 288 patients, who had or had not previously undergone lower abdominal surgery, using the laparoscopic method. We started all patients with the TEP method. We switched to the TAPP method in 29 patients due to some factors such as age, comorbidities, adhesions secondary to the previous operation (10%), and perironeal tears >3 cm. The conversion rate from TEP to TAPP is estimated to be around 3%–5% in the literature, ¹ but it can vary depending on surgeon experience and patient factors.

The aim of this study was to show that intervention from both sides of the peritoneum with TEP and TAPP techniques allows hernia surgeries to be performed laparoscopically in patients who have previously undergone lower abdominal surgery.

Patients and Methods

The research protocol was approved by Istanbul Medipol University Ethics’ Committe (E-10840098-202.3.02-2238). All procedures in the study were performed in accordance with ethical principles and the Declaration of Helsinki.

This was a double center, prospective, observational study of 288 patients (aged >36) who underwent laparoscopic hernia repair for inguinal and scrotal hernias between May 2018 and May 2023, performed by two surgeons with 20 years of experience. Patients were classified in two groups who had not previously undergone abdominal surgery (n = 216) (Group I) and who had surgery (n = 72) (Group II). Of the 72 patients, 7 had cesarean section, 24 had inguinal hernia, 21 had open appendectomy, 6 had laparoscopic appendectomy, 1 had undescended testicle, 8 had varicocele, and 5 had colon resection before. All patients were throughly questioned and examined on an outpatient department basis and admission individually. They were admitted to hospital on the day of surgery. The preanesthetic evaluation was performed by two corresponding anesthesia team. In our study, emergency cases were excluded. The operation was started with the TEP technique in all patients.

All patients were positioned in supine for the surgery. A 15 mm incision was made in the skin below the umbilicus. This revealed the anterior rectus sheath, from which a horizontal 10 mm incision was made. After exposing the rectus muscle, the preperitoneal space behind the muscle was bluntly dissected using kelly clamps. The preperitoneal space was then expanded into the extraperitoneal space using a 10 mm balloon trocar (Covidien, Parkway, MN, USA). The balloon was removed and carbon dioxide gas was insufflated into the extraperitoneal space at a pressure of 10 mmHg. A 30-degree videoscope was inserted through a port, a 5 mm trocar port was placed 3 cm above the symphysis pubis, and another 5 mm trocar was placed between the camera port and the suprapubic port. The preperitoneal space was dissected and the hernia sac was atraumatically retracted using forceps. The inferior epigastric artery and vein were identified, and the Hasselbach’s triangle (for direct hernias) and the structures containing the ligamentum teres uteri in females (for indirect hernias) were identified. The hernia sac was dissected laterally from the cord and separated. A 10 × 15 cm prosthetic graft (prolene mesh) was introduced through the camera port and positioned on the anterior abdominal wall covering the Hasselbach’s triangle or internal inguinal ring. The graft was secured to the pubic tubercle using absorbable Tacker™ fixation device (Covidien). The surgery was performed by the same surgical team in both groups. Standard TEP surgery was performed as per procedure. Two hundred fifty-nine patients were operated with TEP method. TEP method was converted to TAPP in 9 patients from Group I and 20 patients from Group II due to some factors such as age, comorbidities, adhesions secondary to the previous operations (10%) (1 patients had laparoscopic and 4 open appendectomy, 1 had varicocele, 1 had undescended testicles, 4 had repeated caesarean section, 4 had colon resection through a lower midline incision, 5 had hernia repair), and perironeal tears >3 cm. The mean operative time was 42.23 ± 16.84 in patients who had not had lower abdominal surgery before, while it was 44.76 ± 17.62 in patients who had had lower abdominal surgery before (P = .324). Postoperative complications; SSI, scrotal edema, seroma complaints were observed. Follow-up of the patients was done at 1 week, 1 month, 3 month, 6 month, and 1 year intervals.

Demographic variables including age, Body Mass Index (BMI), American Society of Anaestheriologists (ASA) score, type of anesthesia based on ASA score, European Hernia Society (EHS) classification (hernia type: medial, lateral, inguinal, scrotal), defect size, peritoneal tear, conversion, and postoperative complication rates, including scrotal edema, seroma, and surgical site infection (SSI) depending on the surgeon and patient-related variables were recorded.

Results

A total of 288 patients underwent laparoscopic hernia repair. The operation was started with the TEP technique in all patients. The distribution of demographic characteristics of the patients, ASA, anesthesia type, BMI, operation side, hernia type, hernia side (unilateral & bilateral), defect size, conversion rate, peritoneal tear measured during surgery, and postoperative complications (scrotal edema, seroma, surgical site infection) is shown in Table 1. The average age of the Group II and the Group I was very close to each other (P = .887). The majority of patients were male (n = 268). No significant difference was observed between the ASA distributions of the patients who underwent preoperative anesthesia examination in both groups (P = .907). BMI values were close to each other in both groups (P = .633). There was no significant difference between Groups I and II in terms of hernia type, postopereative complications, SSI, scrotal hernia, defect size, and laterality. The distributions of conversion and peritoneal tear 5 mm and >6 mm–3 cm in Group II were found to be statistically significantly higher than Group I (P = .0001).

Logistic regression analysis was performed with peritoneal tear and conversion variables to determine the factors affected in the presence of Group II (Table 2). The risk coefficient for a peritoneal tear with a diameter of 5 mm is 2.25 (1.01–5.04) (P = .049), and the risk coefficient for the presence of transformation for a tear with a diameter of 6 mm–>3 cm is 4.35 (2.04–9.28) was measured as (P = .01). The risk coefficient obtained for peritoneal tears >3 cm was evaluated as significant. The risk coefficient for the presence of conversion was 5.82 (2.73–7.99) (P = .0001). It was found to be statistically significant.

The patients were again divided into two groups according to the absence or presence of peritoneal tear and the distribution of existing factors was re-evaluated (Table 3). There was no statistically significant difference in terms of average age, gender, ASA, hernia type, anesthesia type, seroma, SSI between both groups. The BMI averages of the Peritoneal Tear (+) group were found to be statistically significantly higher than the Peritoneal Tear (−) group (P = .038). Additionally, the distributions of L2, L3 hernia type, scrotal edema, scrotal hernia, conversion, defect size 2–3 cm and 3–5 cm, and peritoneal tear 5 mm and >6 mm–3 cm in the were also examined. Statistical data in Peritoneal tear (+) group were found to be significantly higher than the Peritoneal Tear (−) group (P = 0.0001).

Logistic regression analysis was performed with BMI, scrotal edema, scrotal hernia, conversion, and defect size variables to determine the factors affecting the presence of peritoneal tear (Table 4). BMI (P = .454), scrotal hernia (P = .162), and defect size (P = .087) were found to be statistically insignificant. The risk coefficient for scrotal edema was found 7.18 (3.04–9.98) (P = .0001), the risk coefficient for conversion is 8.89 (3.89–10.47) (P = .0001), the risk coefficient for scrotal hernia is 9.72 (4.40–16.79) (P = .0001) was found statistically significant. In the presence of peritoneal tear, the risk of scrotal edema and conversion was increased.

Operative time was similar for both technique. There was no serious complications during surgery. Scrotal edema was documented in 27 patients in Group I and 14 in Group II. Scrotal support applied by suspender panties for these patients. The problem resolved in one week. Surgical site infection were seen in only two patients in Group I. The BMI of these patients was over 30. Infections in port areas improved with oral antibiotic treatment.

A total of 47 patients developed seroma. Forty-three of them resolved spontaneously within a few days, but four of our patients with cardiac disease were drained only once. Average length of stay in hospital was 2 days.

Discussion

Prior lower abdominal surgery does not necessarily prevent someone from undergoing laparoscopic hernia repair. However, the presence of a more prominent scar due to the larger incision size secondary to open lower abdominal surgeries may make the laparoscopic procedure more difficult for the surgeon. Additionally, open lower abdominal surgeries mean an increased risk of wound infection and longer recovery time according to laparoscopic surgery.

In previous studies, both TAPP and TEP techniques have been shown to be safe and effective for inguinal hernia repair, providing comparable results in terms of complications, recurrence rates, and recovery.^2,3 In addition, some studies argue that the TAPP method is more advantageous for scrotal hernias and incarcerated hernias. ⁴ In our study, 200 patients in Group I and 68 patients in Group II had inguinal hernia; 16 patients in Group I and 4 patients in Group II were operated on due to scrotal hernia. TEP method was converted to TAPP in 9 patients with scrotal hernia and 20 patients with inguinal hernia due to irreparable peritoneal tear.

Bilateral inguinal hernias occur when there is a weakness in the abdominal wall, specifically in the myopectineal orifice region. This allows abdominal contents to bulge through the inguinal canal on both sides of the body. Surgery is generally required to repair inguinal hernias and prevent complications such as bowel obstruction or strangulation. In the past, the most common surgical approach was an open repair, where a single large incision is made to access the hernias and repair them with sutures or a mesh patch. However, over time, a less invasive approach called laparoscopic or minimally invasive surgery has become more common. This technique involves making small incisions and using a tiny camera to approach the contra lateral groin and specialized surgical tools to repair bilateral hernias. ⁵ Since laparoscopic surgery involves smaller incisions, there is a reduced risk of wound-related complications such as wound infections and hernia formation at the incision site compared with open surgery. ⁶ In Group I, 177 of the hernias were unilateral and 39 were bilateral; In Group II, 63 of the hernias were unilateral and 9 were bilateral. In patients with bilateral inguinal hernia who had previously undergone midline surgery, the TEP method could not be applied because a tear occurred in the peritoneum during the placement of the first port behind the rectus abdominis muscle. Lateral abdominal surgery has minimal impact on the TEP procedure.

Proper space creation allows for precise and controlled movements during the procedure, reducing the risk of injury to surrounding structures like inferior epigastric artery and ensuring that the repair is carried out accurately. Difficulty in visualizing the hernia defect or surrounding anatomy, leads to increased risk of peritoneal tears and injury to organs or blood vessels and it is a predisposing factors for conversion to open surgery. ⁷ Adequate space may help streamline the surgical process, make the procedure more efficient and potentially shorten overall operating time and reduce the high rate of conversion from TEP to open surgery described in previous studies. ² In our study, 9 patients in Group I and 20 patients in Group II TEP converted to TAPP. Nine of these patients had scrotal hernia and 20 had inguinal hernia. Twenty of these 29 patients had previously undergone lower abdominal surgery (laparoscopic and open appendectomy, varicocele, undescended testicle, cesarean section, colon resection through lower midline incision, lichtenstein hernia repair). Fifteen of the 29 patients who underwent conversion were L2 according to the EHS classification. These patients had previously undergone surgery for open appendectomy and groin hernia. The remaining ones were L3 and M3, respectively. The reason for switching from TEP to TAPP was that the peritoneal tear was >3 cm and sufficient space could not be created. There was no conversion to open surgery.

Both TAPP and TEP approaches for inguinal hernia repair carry the risk of visceral and vascular injuries, but the incidence may vary between the two techniques. In TAPP (0.21%), visceral injuries are reported to be slightly more common compared with TEP (0.11%), ⁶ while vascular injuries, especially involving the inferior epigastric artery, are more frequently seen in TEP. ⁸ Our study reported no intraoperative complications in hernia repairs by TEP and TAPP.

The incidence of chronic pain after laparoscopic hernia repair is approximately 3%, ⁹ and in studies with a follow-up period longer than 12 months, no significant difference was found between patients who underwent TAPP and TEP methods. In TAPP surgery, the handling of the peritoneum and potential irritation of the nerves in the abdominal wall can sometimes lead to more pain as reported by Krishna et al. ¹⁰ On the other hand, in TEP surgery, postoperative pain is less compared with TAPP surgery, as there is no direct contact with the peritoneum and potentially less irritation of the abdominal wall nerves. The placement of mesh or sutures, can contribute to postoperative pain if not done meticulously or if there is tension on the repair site during TAPP procedure.^11,12 Many other studies have found no difference in pain between TAPP and TEPP procedures^10,13 as in our study.

Bilateral hernias and indirect hernias are associated with higher post-operative pain levels, as per the cited research. ¹ Contrary to the study by Bansal et al. they found that patients who underwent TEP hernia repair for unilateral hernias experienced less pain in the early postoperative period compared with TAPP repair.^14,15 Since pain is a subjective concept, the data about it may differ from study to study.

During the intermittent follow-up of our patients until the end of the first year after surgery, acute pain was observed in the first week after surgery in bilateral hernias performed with the TAPP method. Our patients never complained of chronic pain.

The hospital stay for a laparoscopic hernia operation is typically short, usually ranging from a few hours to one night in the hospital. In the meta-analysis by Bracale et al., patients who underwent TAPP technique had a longer hospital stay. ¹⁶ In our study, the longest hospital stay was 2 days.

Seroma formation after TAPP and TEP techniques of hernia repair occurs due to the accumulation of fluid in the surgical area. This can happen when lymphatic vessels are disrupted during the surgery, leading to the leakage of lymphatic fluid into the space created during the procedure. Seromas are common after both TAPP and TEP hernia repairs, with the incidence varying depending on factors such as the patient’s individual characteristics and the type of surgery performed.

In one study, the incidence of seroma was between 0.5% and 12.2% and between 3% and 8% after TEP and TAPP repair, respectively. ¹⁷ Krishna et al. ¹⁰ reported that seroma was seen more frequently (28%) in the TEP method, which is mostly preferred in inguinal hernia operations. In our study, the incidence of seroma was 16.31%. In our study, seroma developed in 38 patients in Group I and 9 patients in Group II. Of the patients who developed seroma, 43 were operated on by the TEP method and 4 by the TAPP method (2 scrotal, 2 inguinal hernias). Seven patients with seroma had scrotal hernia and 40 patients had inguinal hernia (6 bilateral inguinal, 2 bilateral recurrence). Ten patients with seroma had previously undergone lower abdominal surgery. Most of them resolved spontaneously without requiring intervention.

Scrotal edema formation can be seen after TEP and TAPP inguinal hernia repair techniques due to several reasons. One common cause is the accumulation of fluid in the scrotum following surgery, which can result from a variety of factors including venous congestion, or inflammation in the area. Additionally, the positioning of the patient during the surgical procedure may contribute to fluid pooling in the scrotum. The incidence of scrotal edema after TEP and TAPP techniques varies among individuals and may also be influenced by factors such as the surgeon’s technique, patient characteristics, and postoperative care. While scrotal edema is a recognized complication of these procedures, its exact frequency can vary and is not always well-documented in the literature. However, Krishna et al. ¹⁰ detected scrotal edema in the TAPP group (34%) approximately four times more than in the TEP group (9.4%). In our study, scrotal edema developed in 27 patients in Group I and 14 patients in Group II. Of the patients who developed scrotal edema, 30 were operated on due to inguinal hernia and 11 due to scrotal hernia. Fourteen of the patients operated for inguinal hernia and two of the patients operated for scrotal hernia were patients who had previously undergone lower abdominal surgery. TEP converted to TAPP in four patients. Three of the patients converted to TAPP had previously undergone lower abdominal surgery. The choice of surgical approach depends on various factors, including the surgeon’s experience and patient-specific characteristics such as the type of hernia, health condition related to the peritoneal space, and the presence of pulmonary hypertension.

In the literature, the conversion rate from TEP to TAPP is estimated to be around 3%–5%. ¹ In our study, TEP method was converted to TAPP in nine patients in Group I (4.1%). Twenty patients in Group II were switched from TEP to TAPP (27.7%). There was no conversion to open surgery in either group. No study was found in the literature regarding the rate of conversion of the TEP method to TAPP or open surgery in patients who have previously undergone lower abdominal surgery. Our study will probably be the first study on this subject.

Conclusion

Previous abdominal surgeries can create adhesions that may make it more difficult to access the hernia site during laparoscopy. With advancements in surgical techniques and technology, experienced surgeons can perform laparoscopic hernia repair successfully in patients who have had previous abdominal surgeries.