Comparison of Early Results of Laparoscopic Transabdominal Preperitoneal and Total Extraperitoneal Repair in Recurrent Inguinal Hernia

Abstract

Background:

The optimal surgical approach for recurrent inguinal hernia remains controversial. Among the commonly used laparoscopic techniques, transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) repairs are frequently performed, yet data comparing their short-term outcomes in recurrent cases are limited. This study aimed to compare early clinical outcomes of TAPP versus TEP in recurrent inguinal hernia repair.

Methods:

We retrospectively analyzed 48 patients who underwent laparoscopic surgery for recurrent inguinal hernia between January 2022 and April 2024 at two centers. Patients were assigned to TEP (n = 27) or TAPP (n = 21) groups based on surgeon preference. Demographics, intraoperative variables, and postoperative outcomes including recurrence, complications, visual analogue pain scores (visual analogue scale [VAS]), analgesic requirement, urinary retention, seroma formation, and testicular complications, were assessed.

Results:

Baseline characteristics were comparable except for age, which was significantly lower in the TAPP group (47.5 ± 14.1 versus 60.3 ± 10.2; P < .001). No significant differences were observed in operative time, VAS scores, or hospital stay. Although intraoperative bleeding, urinary retention, and seroma were more frequent in the TAPP group, these did not reach statistical significance. No conversions to open surgery occurred in the TEP group, while one was noted in the TAPP group. During a median follow-up of 22 months for TEP and 16 months for TAPP, a single recurrence was observed in the TAPP group (4.8%). Rates of chronic pain were similar between groups.

Conclusion:

Both TAPP and TEP are safe and effective for recurrent inguinal hernia repair, with low complication and recurrence rates. No clear superiority was demonstrated. Surgical technique should be selected based on individual patient and anatomical factors. Further randomized prospective studies are needed to better define the optimal approach in recurrent cases.

Introduction

It has been reported that more than 800,000 inguinal hernia operations are performed in the United States every year.¹ European records show that 15% of all inguinal hernia operations are for recurrent inguinal hernia.² Recurrent inguinal hernia repair is more challenging than primary inguinal hernia repair due to scar and fibrotic tissues in the surgical field and changes in the anatomical structures in the inguinal region. Although the treatment of primary inguinal hernia has been widely researched and clear evidence has been presented, there is still a lack of evidence about the most appropriate approach for recurrent cases, and the most appropriate surgical method is controversial.^3,4

Laparoscopic herniorrhaphy was described in the early 1990s.⁵ In recent years, it has become more popular in both primary and recurrent inguinal hernia repairs. It has been reported that the laparoscopic approach has advantages over open repair such as prevention of scar tissue, simultaneous repair in bilateral hernias, less postoperative pain, early recovery, and earlier return to daily activities.^2,3,6 In addition, in some studies, the recurrence rate was found to be lower after laparoscopic repair compared to open methods, and this was explained as the closure of the entire myopectineal orifice with graft in laparoscopy.⁷

Currently, the most preferred laparoscopic approaches for both primary and recurrent cases are total extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair. TAPP requires access to the abdominal cavity and carries all the risks of the intraperitoneal approach, including involuntary injury of intraabdominal organs. In the TEP technique, a preperitoneal space is created without entering the intraperitoneal space, and the potential risk of organ injury due to intraabdominal adhesions is still present. Anatomical landmarks during preparation in the preperitoneal space using the TEP technique are often described as more complex than with the TAPP technique as they are difficult to identify.⁸

Although there are many studies in the literature comparing the efficacy and surgical results of laparoscopic and open conventional methods in recurrent inguinal hernias, studies comparing the results of TAPP and TEP methods are very limited. The aim of our study is to compare the early results of laparoscopic TAPP and TEP methods in recurrent inguinal hernia and to contribute to the literature on the appropriate methods to be used in these cases.

Materials and Methods

Ethics committee approval for the study was obtained from Acıbadem Mehmet Ali Aydınlar University Faculty of Medicine with the decision numbered 2024-10/452.

Recurrent inguinal hernia patients who were operated laparoscopically at Acıbadem Mehmet Ali Aydınlar Medical Faculty Bakırköy Hospital and Osmaniye State Hospital between January 2022 and April 2024 were analyzed in the study. Out of a total of 72 patients, 48 patients were included in the study according to the inclusion and exclusion criteria.

Demographic data (age, gender, American Society of Anesthesiologists [ASA] score, body mass index [BMI]) primary hernia type [direct, indirect, mixed type] time between primary surgery and recurrence, intraoperative data [complications, conversion, operation time, drainage requirement], postoperative data [analgesic requirement, visual analogue scale or VAS, urinary retention, testicular problems, presence of serological fluid or hematoma, wound site infection, length of stay, chronic pain, presence of recurrence, follow-up period] were retrospectively reviewed and analyzed. The type of surgical approach was selected at the surgeons’ discretion based on individual surgeon expertise, patient-specific anatomical considerations, and safety concerns, reflecting real-world clinical practice and ensuring optimal patient outcomes. A standard 13 × 15 cm Prolene graft was used in both repairs.

Inclusion criteria

•

>18-year-old patients

•

Patients with the first recurrence before primary surgery

•

Patients whose primary surgery type is an open procedure

•

Patients who underwent elective surgery

•

>5 years of experience in laparoscopic inguinal hernia surgery for surgeons

Exclusion criteria

•

ASA 3 patients

•

Patients for whom the data in the data form could not be accessed

•

Recurrence patients operated under emergency conditions

•

Recurrence patients who underwent laparoscopic repair

•

Patients without follow-up

Statistical analysis

Statistical analyses were performed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Categorical variables were presented as percentages (n), while numerical variables were tested for normality using the Shapiro-Wilk test. Normally distributed numerical data were expressed as mean ± standard deviation (SD), whereas non-normally distributed numerical data were reported as median (interquartile range [IQR]). Comparisons between categorical variables were conducted using the chi-square test. For numerical variables, normally distributed data were compared using the independent samples t-test, while non-normally distributed data were analyzed with the Mann-Whitney U test. A P value <.05 was considered statistically significant.

Results

A total of 48 patients were included in our study. They were divided into two groups as TEP and TAPP. The number of patients who underwent TEP was 27 and the TAPP group consisted of 21 patients. When demographic data were analyzed, the mean age was lower in the TAPP group and statistically significant (TEP: 60.3 ± 10.2, TAPP: 47.5 ± 14.1, P < .006). There was no difference in gender (TEP: 100% [n:27], TAPP: 95.2% [n:20]), ASA score (P = .110), mean BMI (TEP: 26.07 ± 2.09, TAPP: 26.76 ± 5.28). The interval between primary surgery and recurrence was longer in the TAPP group (TEP: 8.00 [5.00–10.00] months, TAPP: 10.00 [8.00–20.00] months) (Table 1).

Table 1.

Demographic Relations Between Surgery Types

	TEP (n = 27)	TAPP (n = 21)	P value
Age	60.3 ± 10.2	47.5 ± 14.1	<.001
Gender			.252
Male	100% (27)	95.2% (20)
Woman	0	4.8% (1)
ASA			.110
1	70.4% (19)	47.6% (10)
2	29.6% (8)	52.4% (11)
BMI	26.07 ± 2.09	26.76–5.28	.289
Time between primary surgery and recurrence (months)	8.00 (5.00–10.00)	10.00 (8.00–20.00)	.006

P > .050 written in bold.

ASA, The American Society of Anesthesiologists (ASA) physical status classification system; BMI, body mass index; TAPP, laparoscopic transabdominal preperitoneal repair; TEP, total extraperitoneal repair.

When intraoperative complications were evaluated, the rate of bleeding was higher in the TAPP group but not statistically significant (TEP: 37.0% [n:1], TAPP: 19.0% [n:4], P = .084). Drain use was higher in the TEP group, but no statistical difference was found (TEP: 37.0% [n:10], TAPP: 19.0% [n:4], P = .174). There was no conversion to open in patients who underwent TEP, whereas 1 patient in the TAPP group was converted to open. The operation times were similar in both groups. Intraoperative data are shown in Table 2.

Table 2.

Statistics of Intraoperative Complications

	TEP	TAPP	P value
Conversion	0	4.8% (1)	.252
Use of drains	37.0% (10)	19.0% (4)	.174
Intraoperative bleeding/complication	3.7% (1)	19.0% (4)	.084
Operation duration	55 (45–65)	50 (40–70)	.722

TAPP, laparoscopic transabdominal preperitoneal repair; TEP, total extraperitoneal repair.

There was no statistically significant difference in the need for narcotic analgesic, VAS score, urinary retention, testicular problem, wound site infection, presence of hematoma and seroma and length of hospitalization between the two groups. No wound site infection was observed in both groups, VAS, postoperative narcotic analgesic requirement, rate of testicular problems and length of hospitalization were similar. The rates of urinary retention (TAPP: 19.0% [n:4], TEP: 7.4% [n:2]) and seroma (TAPP: 19.0% [n:4], TEP: 7.4% [n:2]) were higher after TAPP. Postoperative characteristics are shown in Table 3.

Table 3.

Statistics of Postoperative State Complications

	TEP	TAPP	P value
The need for narcotic analgesics	22.2% (6)	28.6% (6)	.614
VAS	3.00 (2.00–4.00)	4.00 (2.00–5.00)	.166
Urinary retention	7.4% (2)	19.0% (4)	.226
Testicular problem	7.4% (2)	4.8% (1)	.707
Wound site infection	0	0	N/A
Seroma	7.4% (2)	19.0% (4)	.226
Ecchymosis/hematoma	7.4% (2)	9.5% (2)	.792
Length of hospitalization	1.00 (1.00–1.00)	1.00 (1.00–1.00)	.597

BMI, body mass index; TAPP, laparoscopic transabdominal preperitoneal repair; TEP, total extraperitoneal repair; VAS, visual analogue scale.

The mean follow-up period was 16 months for the TAPP group and 22 months for the TEP group. Long-term pain data were similar for both groups (TAPP: 9.5% [n:2], TEP: 11.1% [n:3, P = .858]). There was no recurrence in the TEP group during the follow-up period, while 1 patient in the TAPP group had recurrence at postoperative 16th month. Follow-up data are shown in Table 4.

Table 4.

Comparisons of Long Term Variables

	TEP	TAPP	P value
Follow-up time	22.00 (13.00–28.00)	16.00 (13.00–19.00)	.047
Long-term pain	11.1% (3)	9.5% (2)	.858
Presence of recurrence	0	4.8% (1)	.252

P > .050, written in bold.

TAPP, laparoscopic transabdominal preperitoneal repair; TEP, total extraperitoneal repair.

Discussion

TAPP and TEP are safe and feasible methods in recurrent inguinal hernias considering the short-term results of our study and the literature. International guidelines and European guidelines consider both techniques as a single entity. Both can be performed with low postoperative morbidity and complication rates in patients with recurrent inguinal hernia.

There are studies that TEP repair is performed between the parietal peritoneum and the anterior abdominal wall and that, in contrast to TAPP repair, the integrity of the peritoneum is intact, resulting in lower pain scores.^9,10 In the meta-analysis of randomized controlled trials (RCTs) comparing TAPP and TEP methods by Chen et al., pain was significantly less in patients undergoing TEP at 1 week postoperatively in primary cases, while pain scores were similar in the two groups at 3 and 6 months. This was again attributed to the extraperitoneal approach being associated with less peritoneal irritation.¹¹ In the same study, analgesic consumption in recurrence cases was not different between the two groups, probably because some terminal sensory branches were damaged during the previous operation. However, in this study, there was a lack of data on the type of surgical approach to which the patients were previously exposed.¹¹ Krishna et al. reported comparable pain scores for both techniques, further substantiating their non-inferiority¹² According to our results, there is no significant difference in pain between the two groups.

There are studies reporting that the surgical time was significantly shorter in the TAPP group in recurrent inguinal hernia surgery. It was thought that this may be due to factors such as sutures or scars from the previous repair, making it difficult to create and preserve space in TAPP repair. Because the preperitoneum area is smaller and more difficult to dissect than the peritoneal cavity in the original anatomy.^13,14 Gass et al. in their study of 1309 patients who underwent TAPP and TEP in recurrent inguinal hernia concluded that TEP was associated with a higher rate of intraoperative complications and a longer operative time. There was no statistically significant difference in surgical postoperative complications, general postoperative complications and conversion rates. It was also shown that the postoperative hospital stay was longer for patients undergoing TAPP repair.⁸ A 2015 systematic review and meta-analysis of RCTs reported that there was no significant difference between TAPP and TEP in terms of recurrence rate, return to work, length of hospital stay, and total complications.¹⁵ Karthikesalingam et al. conducted a meta-analysis of RCTs, suggesting that while laparoscopic approaches can effectively repair recurrent inguinal hernias, there is no significant difference in recurrence rates when comparing these techniques¹⁶ Although some of our results support the literature data, some of them show differences in the data. In our study, surgical time was found to be similar in the TAPP and TEP methods. Although the incidence of complications such as presence of seroma, urinary retention, and intraoperative bleeding was higher in the TAPP group, no statistically significant difference was found in any complication data. Duration of operation, hospital stay, and recurrence were similar in both groups.

The relative advantage of laparoscopic repair methods in inguinal hernias that recur after open repair has been demonstrated.¹⁷ In the European Hernia Society guidelines, it was recommended to modify the technique compared with the previous technique and to use a new dissection plane for mesh placement.¹⁸ A study based on the Danish Hernia Database concluded that laparoscopic repair should be recommended if reoperation is required after primary Lichtenstein repair.¹⁹ There is a general consensus that mesh should be used for repair in recurrent cases, but there is no consensus on which technique should be considered the best treatment.^20,21 In a meta-analysis of prospective randomized trials comparing laparoscopic methods and open repairs in recurrent inguinal hernias, Pisanu et al. showed that TAPP and TEP methods have advantages over open methods such as lower recurrence (8.3% versus 11.6%), less chronic pain (9.2% versus 21.5%) and fewer complications of ischemic orchitis. In this study, the only advantage of open surgery over laparoscopic methods was the shorter operation time (54.2 versus 62.9 minutes).²¹ Our study supports the conclusion that both laparoscopic methods are safe and feasible based on data such as intraoperative and postoperative complications, recurrence rates, and length of stay.

There is a lack of research on the preferred treatment of recurrent inguinal hernia after mesh repair, because a large proportion of patients included in randomized trials underwent primary surgical repair at the first operation. The clinical question of the management of recurrent inguinal hernia needs further clarification.

Conclusion

TAPP and TEP are safe methods with low complication rates in recurrent inguinal hernias. In our study, no superiority of either methods was found. Prospective randomized studies on the ideal method in the management of recurrent inguinal hernia are needed.

Limitation

The limitations of our study include the small sample size and retrospective design. We think that a larger patient population may yield more useful results. Allowing surgeons’ discretion introduces selection bias, potentially affecting the generalizability of results. However, this approach enhances patient safety and better reflects real-world practice.

Footnotes

Authors’ Contributions

C.A.: Conception and design, editing, drafting the article, final approval. E.Ç.: Conception and design, drafting the article, revising the article, final approval. B.Y.: Data analysis, revising the article, final approval. A.O.D.: Conception and design, editing, final approval. C.U.: Conception and design, revising the article, final approval.

Patient Consent

Informed consent was taken from the patients.

Ethical Approval

This study is approved by the Ethical Committee of Acibadem Mehmet Ali Aydınlar Üniversitesi (ATADEK) dated 18 July 2024 (Approval No. 2024-10/452).

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This article did not receive any funding.

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