Comparison of Short-Term Results of Total Extraperitoneal Repair Using Balloon Dissection with Mesh Fixation Versus Telescopic Dissection Without Mesh Fixation

Abstract

Background:

Total extraperitoneal (TEP) hernia repair is a minimally invasive method for the treatment of inguinal hernia. In this study, one group with balloon dissection and mesh fixation was compared with another group that underwent telescopic dissection without mesh fixation. This study aims to compare both methods in terms of effectiveness, complications, pain scores, and clinical outcomes.

Material and methods:

This study is a retrospective evaluation of prospectively acquired data from patients in a single-center setting. Patients were divided into two groups: Group 1, who underwent balloon dissection with mesh fixation, and Group 2, who underwent direct telescopic dissection without mesh fixation. All operations were performed by the same surgical team. Predefined data for both groups were compared statistically.

Results:

Among the 115 patients, 66 (57.4%) were in Group 1 and 49 (42.6%) in Group 2. No significant difference was found between demographic characteristics and clinical features for two groups. Surgical times for unilateral and bilateral repairs were similar between the groups. Hospital stay duration was also comparable. The conversion rates to transabdominal preperitoneal were 4.5% in Group 1 and 8.2% in Group 2. Postoperative complications were similar between the groups. However, significant differences were found in pain scores, with Group 1 experiencing higher pain levels on the first day, after 1 week, and after 6 months compared to Group 2.

Conclusion:

Both balloon dissection with mesh fixation and direct telescopic dissection without mesh fixation are safe and effective techniques for TEP hernia repair with similar short-term outcomes. However, balloon dissection and mesh fixation may result in higher postoperative pain levels and incur higher costs. The choice of technique should be guided by available resources, surgeon experience, and patient-specific factors. Further studies are needed to evaluate the long-term outcomes and cost-effectiveness of both approaches.

Introduction

Inguinal hernia is a common surgical problem that affects a significant portion of the general population and requires treatment. Inguinal hernia repair accounts for a large portion of all abdominal wall hernias,¹ and this surgical procedure is one of the most frequently performed interventions worldwide.²

Ralph Ger described the first potential laparoscopic inguinal hernia repair in 1982, but the popularity of this procedure began to increase in the 1990s.³ According to some studies, laparoscopic inguinal hernia surgery can provide results such as less postoperative pain, shorter hospital stay, faster recovery, and lower incidence of chronic pain than open surgery.^4–6 Randomized trials have found no difference in the recurrence rate between the laparoscopic and open approaches.⁷ Various studies recommend laparoscopic repair in the treatment of bilateral inguinal hernia.^8,9

Total extraperitoneal (TEP) repair has gained an important place in inguinal hernia repair with the development of laparoscopic surgical techniques, and this surgery was first used in the treatment of inguinal hernia in in 1992.¹⁰ During TEP repair, the preperitoneal space is created by dissecting the Bogros and Retzius spaces using balloon dissection or telescopic dissection. The balloon dissection technique was first introduced in 1994.¹¹ Although the TEP method offers advantages such as fewer complications and lower recurrence rate, the success achieved from the surgery is greatly affected by the selection of surgical techniques and materials used.^12–14 During TEP repair in inguinal hernia patients, the creation of the extraperitoneal space with a balloon and the use of a tacker to fix the mesh are high-cost procedures.^15,16 These costs may limit the accessibility of surgical interventions, especially in developing regions.

In this study, we aimed to compare the TEP repair method using balloon dissection and mesh fixation with the method using telescopic dissection without mesh fixation, in order to explore more economical and effective alternatives for this surgical intervention.

Material and Methods

Patients who underwent TEP repair in the treatment of inguinal hernia at Mersin University Faculty of Medicine Hospital General Surgery Clinic between January 2021 and January 2024 were included in this study. The study protocol was reviewed and approved by The Board of Ethics Committee of Mersin University on 25/12/2024 with approval 2024/1290, and written informed consent was obtained from all individual participants. The patients who underwent TEP repair for inguinal hernia were retrospectively examined. All patients over the age of 18 with primary inguinal hernia who underwent surgery using TEP technique were included in the study. Patients with complicated (obstructed or strangulated), recurrent inguinal hernias, previous pelvic surgery, lower midline scars, and severe comorbidities, for example, severe cardiac, hepatic or renal disease, were excluded from this study.

Patients were divided into two groups: Group1, which underwent balloon dissection with mesh fixation, and Group 2, which underwent direct telescopic dissection without mesh fixation. The data collected included age, gender, hernia side, the American Society of Anesthesiologists (ASA) score, body mass index (BMI), and factors such as the presence of comorbidities and smoking, studied for both groups. Parameters such as surgery duration, length of hospital stay, pain score, narcotic analgesic requirement, postoperative complications (scrotal edema, seroma formation, incision infection, and urinary retention, and inguinal pain) (first day, after 1 week, and after 6 months) and cost were compared for both groups.

Technique

All operations were performed by the same surgical team. All patients received a single dose of prophylactic antibiotics before surgery (cefazolin 1 g intravenos). The patient was placed in supine position. The surgeon and an assistant stood on contralateral side of the hernia, and the monitor was positioned on the same side as the hernia. The bladder was decompressed with Foley catheter. All operations were performed using 3 conventional laparoscopic trocars. Under direct vision, one 10-mm trocar for the camera (30 degree) was inserted in infraumbilical region, and incise the anterior rectus sheath transversely. Retract the rectus muscle laterally to allow the placement of a 10 mm blunt trocar. Then, the other two 5-mm working ports were placed vertically in the midline.

In Group 1, a laparoscopic dissection balloon (Spacemaker pro Access and Dissector system; Covidien, USA) was placed in the ipsilateral rectus sheath. The balloon was pumped 20–25 times with air under direct visual guidance to open the preperitoneal space. The balloon was then replaced with a 30° laparoscopic blunt trocar and CO₂ gas inflation was performed in the preperitoneal space. In Group 2, blunt digital dissection was performed from the ipsilateral anterior rectus sheath to the preperitoneal space. The space was then inflated with CO₂ gas and a 30° laparoscopic blunt trocar was placed into the preperitoneal space. The dissection was continued with the laparoscope under direct vision. After the dissection is completed and the hernia sac is reduced, a 15 × 10 cm rolled piece of mesh is placed into the preperitoneal space through a 10 mm umbilical trocar. The mesh is positioned to completely cover the direct, indirect, and femoral hernia spaces (myopectineal orifice). In Group 1, the mesh was fixed to the Cooper’s ligament and the anterior abdominal wall with three to four tackers. In the Group 2, the operation was concluded after spreading of the mesh without any fixation.

Statistical analysis

When performing continuous data statistics, mean and standard deviation, minimum and maximum values of features were used; while defining categorical variables, number and percentage values were used. Student’s t test statistics were used in the evaluation of mean difference of continuous measurements according to Stump Closure Method. Chi-Square test statistics were used to evaluate the relationship between Stump Closure Methods and categorical variables. The statistical significance level of the data was taken as P < .05. IBM SPSS 25 statistical package program was used in the evaluation of the data.

Results

A total of 115 patients who underwent surgery for primary inguinal hernia using the TEP method in our clinic between January 2021 and January 2024 were included in the study. The patients were divided into two groups as those who underwent balloon dissection and mesh fixation (Group 1) and those who did not undergo direct telescopic dissection and mesh fixation (Group 2). There were 66 patients (57.4%) in Group 1 and 49 patients (42.6%) in Group 2. In total, 91.3% of the patients (105 patients) were male and 8.7% (10 patients) were female. The mean age of the patients was 52.6 ± 13.7 years, and in the distribution of hernia sides, 49 patients (42.6%) had right hernia, 46 patients (40%) had left hernia, and 20 patients (17.4%) had bilateral hernia. According to ASA scores, 11.3% (13 patients) of the patients were classified as ASA 1, 80.9% (93 patients) as ASA 2, and 7.8% (9 patients) as ASA 3.

In the comparison between the two groups, the mean age of Group 1 was 53.1 ± 12.9 years, while Group 2 had a mean age of 51.9 ± 14.6 years. There was no statistically significant difference in the average age between the two groups (P = .34). Furthermore, the gender distribution was quite similar, with 90.9% males and 9.1% females in Group 1, and 91.8% males and 8.2% females in Group 2. The gender difference was also not statistically significant (P = .99). The presence of comorbidities and smoking history was also evaluated, and no statistically significant difference was found between the two groups regarding these factors (P > .05). A similar distribution was observed between the two groups in terms of ASA scores. In Group 1, ASA 1 (10.6%), ASA 2 (80.3%), and ASA 3 (9.1%) rates were determined, while in Group 2, ASA 1 (12.2%), ASA 2 (81.6%), and ASA 3 (6.1%) rates were determined. There was no statistically significant difference between these findings (P = .78). Similarly, the average BMI was calculated as 24.2 ± 2.7 kg/m² in Group 1 and 23.9 ± 2.8 kg/m² in Group 2. The difference between the BMI values was also not significant (P = .81).

When examining the operation times, the average duration of unilateral surgeries in Group 1 was found to be 66.1 ± 8.5 minutes, while the duration of bilateral surgeries was 88.7 ± 9.2 minutes. In Group 2, the average unilateral operation time was 68.3 ± 9.7 minutes, and the bilateral operation time was 90.1 ± 10.4 minutes. There was no statistically significant difference between the two groups in terms of unilateral and bilateral operation times (P = .65). The length of hospital stay was similar in both groups, with an average of 1.6 ± .5 days in Group 1 and 1.5 ± .4 days in Group 2. No significant difference was found between the length of hospital stay (P = .82).

In addition, the conversion rates to the trans abdominal pre-peritoneal technique were 3 patients (4.5%) in Group 1 and 4 patients (8.2%) in Group 2. There was no statistically significant difference in the conversion rates between the two groups (P = .68).

Similar findings were obtained in terms of postoperative complications. In Group 1, scrotal edema was 6.1% (4 patients), seroma formation was 7.6% (5 patients), incision infection was 3% (2 patients), urinary retention was 4.5% (3 patients), and groin pain continuing at 6 months was 4.5% (3 patients). In Group 2, scrotal edema was 6.1% (3 patients), seroma formation was 6.1% (3 patients), incision infection was 2% (1 patient), urinary retention was 4.1% (2 patients), and groin pain continuing at 6 months was 4.1% (2 patients). There was no significant difference between these complications between the two groups (P > .05). However, a significant difference was observed in the pain scores between the two groups. Pain was evaluated using a scale from 0 to 10, and a score was assigned based on the pain level of each patient. Group 1 had significantly higher pain scores on the first postoperative day, 1 week after surgery and at 6 months compared to Group 2 (P < .001). This finding indicates that Group 1 patients, who underwent balloon dissection and mesh fixation, experienced more pain during the early postoperative period and in the long term (at 6 months) compared to Group 2 patients.

When a cost analysis was conducted, it was observed that the average cost increased by 600 ± 100 dollars for the first group of patients who underwent balloon dissection and mesh fixation. This cost increase is attributed to the additional equipment and procedural requirements associated with the balloon dissection technique.

Table 1 provides a clear comparison of the two groups in terms of evaluation of relationship/difference between demographic and clinical characteristics.

Table 1.

Comparison of Patient Demographic and Clinical Characteristics with Outcomes

	Balloon dissection with mesh fixation group (group 1) n = 66	Direct telescopic dissection without mesh fixation group (group 2) n = 49	Total patients	P value
Age (Mean±SD)	53.1 ± 12.9	51.9 ± 14.6	52.6 ± 13.7	.34
Gender (n%)				.99
Male	60 (90.9%)	45 (91.8%)	105 (91.3%)
Female	6 (9.1%)	4 (8.2%)	10 (8.7%)
ASA Score (n%)				.78
ASA 1	8 (12.1%)	5 (10.2%)	13 (11.3%)
ASA 2	52 (78.8%)	41 (83.6%)	93 (80.9%)
ASA 3	6 (9.1%)	3 (6.1%)	9 (7.8%)
BMI (Mean±SD)	24.2 ± 2.7 kg/m²	23.9 ± 2.8 kg/m²	24.1 ± 2.7 kg/m²	.81
Patients with hypertension (n%)	4 (6.1%)	4 (8.2%)	8 (6.9%)	.94
Patients with diabetes mellitus (n%)	6 (9.1%)	7 (14.3%)	13 (11.3%)	.56
Patients who smoke (n%)	17 (25.8%)	15 (30.6%)	32 (26.1%)	.71
Hernia side				.744
Right (n%)	27 (40.9%)	22 (44.9%)	49 (42.6%)
Left (n%)	26 (39.4)	20 (40.8%)	46 (40%)
Bilateral (n%)	13 (19.7%)	7 (14.3%)	20 (17.4%)
Surgical outcomes
Operative duration (Mean±SD)				.65
Unilateral	66.1 ± 8.5	68.3 ± 9.7	67.1 ± 9
Bilateral	88.7 ± 9.2	90.1 ± 10.4	89.3 ± 9.7
Conversion to another technique (n%)	3 (4.5%)	4 (8.2%)	7 (6.1%)	.68
Length of hospital stay (Mean±SD)	1.6 ± .5 day	1.5 ± .4 day	1.6 ± .5	.82
Postoperative complications
Scrotal edema (n%)	4 (6.1%)	3 (6.1%)	7 (6.1%)	.96
Seroma formation (n%)	5 (7.6%)	3 (6.1%)	8 (6.9%)	.98
İncision infection (n%)	2 (3%)	1 (2%)	3 (2.6%)	.95
Urinary retention (n%)	3 (4.5%)	2 (4.1%)	5 (4.3%)	.96
Postoperative pain
Pain after 1 day (Mean±SD)	7.83 ± 1.13	6.47 ± 1.39	7.25 ± 1.24	<.001
Pain after 1 week (Mean±SD)	4.65 ± .79	2.06 ± .90	3.54 ± .83	<.001
Pain after 6 months (Mean±SD)	2.27 ± 1.05	0.63 ± .81	1.57 ± .94	<.001

ASA, American Society of Anesthesiologists; BMI, body mass index; SD, standard deviation.

Discussion

There were no significant differences in variables such as demographic characteristics, ASA score, BMI, age, and gender between the groups. In addition, the presence of comorbidities and smoking history were found to be similar between both groups (P > .05). These results show that both surgical techniques can be applied to patients with similar disease profiles.

When the surgery times were examined, no significant difference was observed between the two groups in our study. This finding contrasts with some studies that suggest balloon dissection and mesh fixation could increase the surgery duration.^17,18 However, similar to the results reported by Kolli et al. and Aktürk et al. no significant effect on surgery time was observed in their studies.^19,20 This result indicates that the surgical technique does not significantly affect operation duration, and the choice of technique can be guided by the surgeon’s experience and technical preferences.

The amount of time people had to stay in the hospital after surgery was pretty much the same no matter the method used. This tells us that patients were healing at the same pace with either method, meeting all the same recovery checkpoints before being discharged, and so it seems both techniques allow folks to convalesce equally well post-op. However, previous studies have shown that patients in the non-mesh fixation group tend to return to activity more quickly.²¹

In our study, similar results were obtained regarding postoperative complications. The most common complications observed in both groups were scrotal edema and seroma formation. These types of complications are commonly seen in inguinal hernia surgery performed with the TEP method and are consistent with the literature. Additionally, complications such as urinary retention and wound infection were observed at low rates in both groups. A study comparing TEP repair using balloon dissection with telescopic dissection observed similar postoperative complication rates between the two techniques.²² The literature indicates that scrotal edema and seroma formation are commonly seen in both the mesh fixation and non-fixation groups. Additionally, both techniques demonstrate a comparable safety profile with respect to short-term postoperative outcomes.²³ In the present study, the low incidence of complications indicates that both surgical techniques are safe and that the risk of serious complications is minimal.

Many studies comparing balloon dissection and telescopic dissection have observed no significant difference in postoperative pain between the two techniques.^17–22 However, it is well known that there is a distinct difference in pain levels associated with the use of mesh fixation. In particular, cases where mesh fixation is applied have been reported to experience higher levels of postoperative pain.²⁰ In our study, the combination of balloon dissection and mesh fixation appears to have contributed to an increased pain response, suggesting a potential synergistic effect on postoperative discomfort.

The main difference between the two methods lies in cost. Using a balloon dissector and mesh fixation is significantly more expensive than using a telescope dissector without mesh fixation. This price difference can accumulate quickly, especially for hospitals with limited budgets. While the balloon dissector offers ease of use and standardized application, its higher cost may not be justifiable in all settings, particularly when the telescope dissector provides comparable clinical outcomes at a lower expense. Both techniques have distinct advantages. While the telescope dissection method is more cost-effective, it demands greater skill and experience. On the other hand, the balloon dissector, despite being more expensive, offers a simpler and more reproducible approach for extraperitoneal dissection, which may reduce variability in surgical outcomes. Therefore, the choice of technique may depend on available resources and the skill level of the surgical team.

This study has several limitations, including its retrospective design and potential selection bias, as the choice of technique was made by the operating surgeon. Additionally, the study was conducted at a single center with a specific surgical team, which may limit the generalizability of the results. Further prospective, multicenter studies with larger sample sizes are needed to confirm these findings and explore the long-term cost-effectiveness of both techniques.

Conclusion

Authors’ Contributions

The idea and/or hypothesis for the research and/or manuscript were developed by: C.O. and M.A. The planning of methods to achieve the results was carried out by: E.G. and S.B. The project organization, manuscript progression, and oversight were managed by: C.O. and M.A. Data collection and/or processing was conducted by: M.A. Literature review was performed by: H.B. and M.B. The manuscript writing was done by: C.O. and M.A. Critical review was carried out by: T.C and H.C.

Statement of Ethics

The study protocol was reviewed and approved by The Board of Ethics Committee of Mersin University on 25/12/2024 with approval 2024/1290. Written informed consent was obtained from all the patients for this study.

Footnotes

Data Availability Statement

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding authors.

Author Disclosure Statement

The authors have no conflicts of interest to declare.

Funding Information

The study received no funding.

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