Evaluation of Surgical Results and Effectiveness of Laparoscopic Transabdominal Preperitoneal and Laparoscopic Totally Extraperitoneal Approaches in Bilateral Inguinal Hernia Repair: A Randomized Analysis

Abstract

Background:

Laparoscopic surgery is recommended as the standard approach for bilateral inguinal hernia repair. There are few studies in the literature comparing laparoscopic transabdominal preperitoneal (TAPP) and laparoscopic total extraperitoneal (TEP) approaches for bilateral inguinal hernia repair. This study aimed to compare the surgical outcomes and effectiveness of laparoscopic TAPP and laparoscopic TEP methods applied in bilateral inguinal hernia repair.

Methods:

A total of 100 patients operated on for bilateral inguinal hernia by applying laparoscopic TAPP and laparoscopic TEP methods from January 2016 to March 2023 were included in the study. The patients were randomized equally in two groups. Postoperative follow-up results were statistically analyzed in terms of recurrence rate, swelling in the incisions, scrotal edema and swelling, suture dehiscence, and the average time to return to work.

Results:

In bilateral inguinal hernia patients operated with laparoscopic TAPP method compared with bilateral inguinal hernia patients operated with laparoscopic TEP method, postoperative recurrence rate was significantly lower (2% versus 16%), swelling in the incision sites was significantly less (4% versus 24%), and the average time to return to work was significantly shorter (3.6 ± 2.3 versus 6.3 ± 5.8) (P < .05). Scrotal edema and swelling and suture dehiscence results did not show significant differences between the two approaches (P > .05).

Conclusions:

Both methods are widely used in bilateral inguinal hernia repairs. Postoperative results revealed that the laparoscopic TAPP method with less postoperative recurrence rate and less swelling in the incision sites, and shorter average time of the patients to return to work appears to be superior to the laparoscopic TEP method.

Introduction

Inguinal hernia repair is one of the most common surgeries performed in general surgery, with 20 million inguinal hernia repair surgeries performed worldwide each year.¹ In addition to traditional open techniques, minimally invasive approaches are increasingly preferred for managing inguinal hernia repair.^2,3 Minimally invasive approaches appear to be associated with fewer wound-related complications, less postoperative pain, earlier return to work or activity, and less chronic pain compared with the open approach.^4,5 Since its initial description in the early 1990s and due to the emergence of innovative surgical applications, surgical techniques have evolved and laparoscopic transabdominal preperitoneal (TAPP) approach and total extraperitoneal approach (TEP) have emerged.^6,7 Laparoscopic TAPP and laparoscopic TEP methods are commonly applied in bilateral inguinal hernia repair. In this randomized study, long-term inguinal hernia surgery follow-up results performed with the laparoscopic TAPP and laparoscopic TEP technique were analyzed in terms of postoperative recurrence rates, swelling in the incisions, scrotal swelling and edema, suture dehiscence, and average time of the patients to return-to-work. It was aimed to investigate the long-term postoperative results and the effectiveness of these two techniques.

Patients and Methods

This study included statistical analysis of the postoperative outcomes of 100 patients who underwent laparoscopic bilateral inguinal hernia repair surgery in Sultan 2. Abdulhamid Han Training and Research Hospital between January 2016 and March 2023. The inclusion criteria were the patients between the ages of 18–90, in the ASA 1–3 patient group, did not receive antithrombotic treatment and had normal coagulation parameters. The exclusion criteria were the patients with an age of younger than 18 and older than 90, in the ASA 4 group, received antithrombotic treatment and had abnormal coagulation parameters. The patients were randomized equally in two groups based on the laparoscopic TAPP method and laparoscopic TEP method used in the surgery. TAPP group and TEP group results were compared in terms of postoperative recovery and complications. Compared postoperative results were the recurrence rate, swelling in the incisions, scrotal edema and swelling, suture dehiscence, and the average time of the patients to return to work.

In the TAPP method, the diagnosis of the patients was made by physical examination, but some patients also underwent preoperative USG evaluation. Before the surgery, patients were told that they could switch to the open method if necessary. A single dose of antibiotic prophylaxis (Cezol) was administered parenterally to the patients before the first incision in the operating room. All patients were given general anesthesia. After the patient was put to sleep, a urinary catheter was inserted. These catheters were removed on the operating table while the patient was waking up. In the TAPP method, the abdomen was entered under open vision from above the umbilicus, and a 10 mm trocar was inserted. CO₂ was insufflated until the intra-abdominal pressure reached 12 mmHg. Other trocars were then adapted. After the inguinal area was exposed, the overlying peritoneum was opened with the help of endoscissors. After all hernia areas were identified, the prepared 10 × 15 cm mesh was fixed medially to the symphysis pubis with the help of a protucker. After bleeding control, the separated peritoneal leaves were sutured with 3/0 v-lock and the mesh was closed.

In the TEP method, after passing the skin subcutaneous with a 1 cm incision made from the umbilicus inferior. The linea alba was opened, and the right or left rectus muscle was lateralized. A balloon trocar was placed over the posterior rectus cuff, and the preperitoneal area was detached. After CO₂ was administered to the preperitoneal area, two 5 mm working trocars were placed. Symphisis pubis and main vascular structures were revealed. The hernia sac was separated while preserving the cord elements. Subsequently, a 15 × 10 cm prolene mesh was placed in the preperitoneal area and fixed to the symphysis pubis with the help of a protucker. Following bleeding control and CO₂ desufflation, the layers were closed according to their anatomical order.

Results

The mean age of the 100 patients who underwent surgery with laparoscopic TEP and TAPP methods was 57.1 (range 21–81). Ninety-five of the patients were male, and 5 were female. Six patients underwent surgery with preoperative recurrence. Postoperative recurrence was observed in 9 patients, swelling in the incisions in 14 patients, scrotal swelling and edema in 15 patients, and suture dehiscence in 4 of the patients. The average time to return to work was 4.9 ± 4.6 days (range 1–30) days. Table 1 shows the demographic characteristics and surgical outcomes of the patients who underwent surgery by applying laparoscopic TAPP and laparoscopic TEP methods.

Table 1.

Demographic Data and PostOperative Results of the Patients

	Min–Max	Median	Avg. ± SD/n-%
Age	21–81	60	57.1	±	14.3
Gender
Male			95		95%
Female			5		5%
Preop recurrence
Recurrent			6		6%
Primary			94		94%
Postop recurrence
(−)			91		91%
(+)			9		9%
Inguinal hernia side Bilateral			100		100%
Swelling in the incisions
(−)			86		86%
(+)			14		14%
Scrotal swelling and edema
(−)			85		85%
(+)			15		15%
Suture dehiscence
(−)			96		96%
(+)			4		4%
Return to work (day)	1–30	3	4.9	±	4.6

Statistical analysis

In the descriptive statistics of the data, mean, standard deviation, median lowest, highest, frequency, and ratio values were used. The distribution of variables was measured by Kolmogorov–Simirnov and Shapiro–Wilk test. Mann–Whitney U test was used in the analysis of quantitative independent data. Chi-square test was used in the analysis of qualitative independent data. Statistical analysis was performed using SPSS (Statistical Package for Social Sciences) version 27.0 software (SPSS Inc., Chicago, USA). Differences were evaluated statistically at 95% confidence interval and were considered statistically significant when P value was <0.05.

Postoperative recurrence was found to be significantly less in bilateral inguinal hernia patients operated with laparoscopic TAPP method (2%) compared with laparoscopic TEP method (16%) (P = .014). Swelling in the incisions were found to be significantly lower in bilateral inguinal hernia patients operated with laparoscopic TAPP method (4%) compared with laparoscopic TEP method (24%) (P = .04). Mean time of the patients to return to work was shorter in laparoscopic TAPP group (3.6 ± 2.3) compared with laparoscopic TEP group (6.3 ± 5.8) (P = .014). Scrotal edema and swelling results (P = .161) and suture dehiscence results (P = .307) did not show significant differences between the two approaches (Table 2).

Table 2.

Postoperative Data of TEP and TAPP Groups

	TEP group				TAPP group				P
	Avg. ± SD/n-%			Median	Avg. ± SD/n-%			Median	P
Age	57.1	±	14.5	63	57.2	±	14.3	58.5	.783^m
Gender
Male	47		94%		48		96%		.646 ^χ2
Female	3		6%		2		4%
Preop recurrence
Recurrent	1		2%		5		10%		.092 ^χ2
Primary	49		98%		45		90%
Postop recurrence
(−)	42		84%		49		98%		.014 ^χ2
(+)	8		16%		1		2%
Swelling in the incisions
(−)	38		76%		48		96%		.004 ^χ2
(+)	12		24%		2		4%
Scrotal swelling and edema
(−)	40		80%		45		90%		.161 ^χ2
(+)	10		20%		5		10%
Suture dehiscence
(−)	47		94%		49		98%		.307 ^χ2
(+)	3		6%		1		2%
Return to work (day)	6.3	±	5.8	4	3.6	±	2.3	3	.014 ^m

^mMann–Whitney U test/^χ2chi-square test.

TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal.

Discussion

Laparoscopic techniques are standard approaches for treatment of bilateral inguinal hernias. The superiority of the laparoscopic approach over the open technique is that laparoscopic technique provides advantage to address both groins through the same incisions required for unilateral hernia repair.⁸ Laparoscopic approaches in inguinal hernia repair have advantages such as less postoperative pain, faster recovery of patients, and shorter hospital stays compared with traditional open surgery.^9,10 For bilateral inguinal hernia repairs, laparoscopic approaches provide advantages due to less pain and quicker recovery.^11,12

Two important methods used in laparoscopic repair of inguinal hernia are TAPP and TEP techniques.¹³ The TAPP technique provides the advantages of exploring the peritoneal cavity and examining both inguinal regions.⁶ The TEP technique allows exploration of the myopectineal orifices, dissection and reduction of the hernia sac, and placement of the mesh without entering the abdominal cavity.^13,14 There is still debate about which of the most commonly used laparoscopic TAPP or TEP methods should be used in inguinal hernia repair. Postoperative complications and recurrences are among the important measures of surgical outcome in evaluating laparoscopic inguinal hernia repairs. The success of inguinal hernia surgeries is generally evaluated by considering the recurrence rate.¹⁵

In two reviews and meta-analyses, TEP and TAPP methods were compared and found not statistically different in terms of postoperative complications such wound infection, seroma, and hematoma.^16,17 In another meta-analysis, TEP was associated with lower risk of edema, and TAPP was associated with lower risk of formation of seroma.¹⁸ In a review study of 15 randomized controlled trials, no significant difference in terms of recurrence between the TAPP and TEP methods was reported.¹⁹

Most of the comparative evaluations of the laparoscopic TAPP and TEP approaches in the existing literature have been associated with unilateral inguinal hernia repairs, while there are very few randomized studies in which comparative evaluations have been performed for bilateral inguinal hernias. Bilateral inguinal hernia repair by TEP and TAPP were found to have similar outcomes in terms of postoperative complications, postoperative pain, chronic groin pain, and recurrence in another study.²⁰ In a randomized trial comparing laparoscopic TAPP and TEP methods for bilateral inguinal hernia repairs, TAPP method was associated with less postoperative pain scores and shorter mean time to return to work.²¹ The results of our study were compatible with this study in terms of shorter average time of the patients to return to work in TAPP group compared with TEP group. Moreover, in our study, laparoscopic TAPP method was associated with less postoperative recurrence rate and incision swelling.

Conclusion

Laparoscopic surgery is recommended as the standard approach for bilateral inguinal hernia repair. Laparoscopic TAPP and TEP are the two commonly used techniques used in bilateral inguinal hernia repair today. When the postoperative results of the two methods were compared in this study, no statistically significant difference was found in terms of scrotal edema and swelling and suture dehiscence, while the laparoscopic TAPP method was found to be superior to the laparoscopic TEP method in bilateral inguinal hernia repair in terms of postoperative recurrence rate, swelling in the incisions, and the average time for patients to return to work.

Ethical Approval

Ethical approval was acquired from the University of Health Sciences, Hamidiye Clinical Research Ethics Committee. The procedures in the study were conducted in accordance with the Helsinki Declaration-2013.

Footnotes

Disclosure Statement

The author disclosed no conflicts of interest during the preparation or publication of this article. This study received no financial support.

Funding Information

The author has no conflicts of interest or financial ties to disclose.

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