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ORIGINAL ARTICLE
R. Sinha ÆN. Sharma ÆD. Dhobal ÆM. Joshi
Laparoscopic total extraperitoneal repair versus anterior preperitoneal
repair for inguinal hernia
Received: 27 May 2005 / Accepted: 11 December 2005 / Published online: 15 February 2006
Springer-Verlag 2006
Abstract Laparoscopic inguinal hernia repair is still not
the gold standard for repair although mesh implantation
is unequivocally accepted as an integral part of any
groin hernia repair. The aim of the study was to com-
pare the results of anterior preperitoneal (APP) mesh
repair with totally extra peritoneal (TEP) repair for
inguinal hernias. The prospective study was conducted
on 241 patients with 247 hernias (from January 2000 to
June 2004). Anterior preperitoneal repair was done in
121 patients and 120 patients were subjected to TEP
repair. Repair in both groups was done by using Prolene
mesh of size 6·4 in. or 6·6 in. intraoperative and post-
operative parameters and complications were recorded
and the patients were followed up to 1 year post-sur-
gery. For both unilateral and bilateral inguinal hernias,
mean operative time was significantly more in patients of
TEP repair as compared to APP repair (P<0.001) and
significantly more patients had peritoneal tears in the
TEP group (P<0.001). Patients undergoing TEP repair,
however, had significantly less postoperative pain
(P<0.05) and postoperative hospital stay (P<0.05) and
return to work was significantly earlier is this group
(P<0.01 and P<0.001). There was no difference in the
recurrence rate between the two groups. Patients with
inguinal hernias undergoing laparoscopic repair recover
more rapidly, and have less incidence of postoperative
pain. But it takes significantly more time to perform
than APP repair and also the incidence of peritoneal tear
is higher.
Keywords Inguinal hernia ÆAnterior preperitoneal
repair ÆTEP repair
Introduction
With the concept of weakness of the Fruchauds myo-
pectineal orifice as the basis for all forms of groin her-
nias and the inherent tension at the suture line in all
herniorraphies, it seems more logical and anatomical to
reinforce the preperitoneal space over an area well be-
yond the margins of the above orifice. And what better
way to do this than lay in a preperitoneal mesh? But
what is the optimal method of implanting this mesh,
laparoscopic or open method? Recent worldwide figures
still favor the open method and less than 15–20% of
hernias are being done laparoscopically [1]. We set about
assessing the differences in parameters and results of
anterior preperitoneal (APP) mesh repair versus totally
extraperitoneal (TEP) repair for inguinal hernias.
Materials and methods
The prospective study included adult males aged
18 years or more with Nyhus types 2, 3, 4 inguinal
hernia. The patients were alternately assigned to the
TEP repair or the anterior preperitoneal repair group
after matching for age and sex.
Anterior preperitoneal repair was done in 121 pa-
tients with 123 hernias, 109 were indirect, 12 were direct,
2 patients had bilateral hernia and 3 of these had
recurrent hernia. TEP repair was done in 120 patients
with 124 hernias, 107 were indirect and 11 were direct
hernias. There were four bilateral and two recurrent
hernias in this group (Table 1).
Every patient was given 750 mg of cefuroxime
intravenously with the induction of anesthesia. For the
APP repair the inguinal canal was approached interiorly
using an oblique 2 in. incision centered over the deep
inguinal ring. The sac was dissected only at the deep
inguinal ring, transected, ligated proximally and the
distal part left as such. If the sac was small, total dis-
section was carried out and the sac was inverted without
R. Sinha (&)ÆN. Sharma ÆD. Dhobal ÆM. Joshi
Department of Surgery, M. L. B. Medical College,
4/16 Medical College Campus, 284128, Jhansi, UP, India
E-mail: sinha_rga@yahoo.co.in
Tel.: +91-517-2320001
Fax: +91-517-2320002
Hernia (2006) 10: 187–191
DOI 10.1007/s10029-005-0064-0
ligation. The deep inguinal ring was retracted medially
and the preperitoneal space was dissected with blunt
finger and gauze dissection. The extent of dissection was
up to the midline medially, 4–5 cm beyond the deep
inguinal ring laterally. Inferiorly the peritoneum was
stripped away from the external iliac artery and vein and
psoas major and cranially 2–3 cm beyond the arching
fibers of the Transversus abdominis muscle. A 6·4 in.
mesh with a lateral slit of 2 cm for the cord was then
introduced in this space using large artery forceps to
spread the mesh in an angle iron fashion. Interrupted 2-0
Prolene sutures were used to narrow the deep inguinal
ring. No other fixation of the mesh was done.
Laparoscopic repair was carried out under general,
epidural or spinal anesthesia. For the TEP procedure a
2 cm infraumbilical incision was made and the preperi-
toneal space was developed using a balloon dissector.
The balloon dissector was a fingerstall of a surgical glove
tied over the tip of a 5 mm suction cannula and filled
with saline. Two 5 mm ports, one 1 cm suprapubic and
other midway between these two ports were inserted
under direct vision 0.5 cm away from the midline toward
the side opposite to the hernia. After dissection of all
potential hernia spaces and reduction of hernia sac and
its separation from vas deferens and testicular vessels, a
6·4 in. polypropylene mesh was spread evenly to cover
the inguinal floor. The mesh was either secured with two
tacks, one to the pubic tubercle and the other to the
super lateral abdominal wall in direct inguinal hernias or
left as such in indirect inguinal hernias. Intraoperative
parameters, postoperative recovery and complications
were then recorded.
The patients were followed postoperatively up to
1 year. Postoperative pain was classified as scar pain or
neuralgia and graded according to time scale of persis-
tence (1) up to 1 month or (2) more than 1 month
postoperatively.
The significance of the difference in results was cal-
culated by the Student’s ttest and Pvalue of less than
0.05 was taken as significant. For the TEP group, the
operating time in patients after the first 50 was consid-
ered for comparison.
Results
A total of 121 patients were treated by APP and 120
underwent TEP repair. There were 107 indirect, 11 di-
rect, 2 recurrent and 4 bilateral (B/L) inguinal hernias in
the TEP group. In the APP group, 109 patients had
indirect, 12 had direct, 2 had bilateral and 3 had recur-
rent inguinal hernias (Table 1).
Mean operative time in TEP repair was 45.6 min in
the first 50 patients and 31.2 min in the subsequent 34
patients with unilateral (U/L) inguinal hernias. The
corresponding figures for bilateral hernias were 69.2 and
42.1 min. The operating time for APP was 18.8 and
31.7 min for unilateral and bilateral inguinal hernias,
respectively (Table 2). The operative time for both uni-
lateral and bilateral hernias in the APP repair group
was significantly less (P<0.001) as compared to TEP
repair.
Peritoneal tear was seen in 50 patients either as an
obvious tear or as pneumoperitoneum in the TEP group
(P<0.001). Hematoma developed in 1 patient out of 121
Table 1 Types of hernia
Type TPP (n=124, P=120) APP (n=123, P=121)
Direct 11 12
Indirect 107 109
B/I 4 2
Recurrent 2 3
nnumber of hernias, Pnumber of patients
Table 2 Operative and postoperative parameters
Parameters TEP APP Pvalues
Mean operative time (min) U/L n=124 1–50 pts 45.6
>50 pts 31.2 22.2 <0.001
B/L n=123 1–50 69.2
>50 42.1 31.7 <0.001
TEP (120 pts) APP (121 pts)
Peritoneal tears 50 (41.7%) 0 <0.001
Haemotoma/seroma 4 (3.33%) 1(0.83%) >0.05=NS
Wound/post site infection 1 1(0.83%) >0.05=NS
Conversion 4 (3.33%)
Recurrence 4 (3.33%) 2(1.66%) >0.05=NS
Postoperative pain
1 month scar pain 1 (0.83%) 6(4.95%) <0.05
Neuralgia 1 1(0.83%) NS
1 year scar pain – –
Neuralgia – –
Post op hospital stay (days) 2.2 5.1 <0.05
Return to work (days) 10.4 U/L 15.2 <0.01
B/L 20.4 <0.001
U/L unilateral, B/L bilateral
Values with P<0.05 were considered as significant (calculated by Student’s ttest)
188
(0.83%) in APP repair group as compared to 4 patients
out of 120 in TEP group (3.33%) a finding which was
not significantly different (Table 2). Wound infection
was seen in one patient with APP repair and in one
patient with TEP repair. Four (3.33%) patients in TEP
group required conversion to anterior preperitoneal re-
pair. Three because of large peritoneal tears and other
because of adherent peritoneum following a previous
suprapubic cystolithotomy.
Two patients had postoperative urinary retention.
Both were above 60 years of age and had prostato-
megaly. The duration of postoperative hospital stay for
unilateral and bilateral hernias was 2.2 days in the TEP
group as opposed to 5.1 days in unilateral and bilateral
hernia patients subjected to APP (P<0.05). Patients of
unilateral and bilateral hernias went back to work after
10.4 days when operated by TEP repair as compared to
APP repair where it was 15.1 days (P<0.01) and
20.4 days (P<0.001) for unilateral and bilateral hernias
(Table 2).
Six (4.95%) patients in the APP group had scar pain
and one patient had scrotal neuralgia persisting up to
1 month after surgery, while one patient (0.83%) in TEP
group had port site pain over the same duration while
one patient had neuralgia along the lateral aspect of the
thigh. The incidence of scar pain was significantly less in
the TEP patients. Chronic pain was nonexistent in both
groups at 1 year follow-up (Table 2).
Two out of 121 patients in the anterior preperitoneal
repair group had recurrence whereas three out of 120
patients with TEP repair had recurrence. The recur-
rences in TEP repair all occurred in the first 50 patients
with direct inguinal hernias. The recurrence in both the
groups occurred in the immediate postoperative period
within 48–72 h and was due to the displacement of the
mesh. Subsequently there were no recurrences.
Discussion
The preperitoneal reinforcement of the Fruchauds ori-
fice is unarguably the most logical method of hernio-
plasty, because one, the first containing layer, the
transversalis fascia is being reinforced and second, it
involves minimal alteration in the anatomy of this re-
gion. The open preperitoneal approach utilizes the
anterior access as in the Mahroner Goss approach [2]or
the posterior access as in Rives Stoppa approach [3].
This preperitoneal placement of mesh was not a com-
monly done procedure until Stoppa, who through a
midline incision repaired bilateral inguinal hernias and
named it as giant prosthetic replacement of the visceral
sac, rekindled interest [4]. It is but an extension of this
approach, which has been taken up as the TEP, for groin
hernias. The TEP procedure combines the advantage of
tension free mesh reinforcement of the groin with those
of laparoscopic surgery with its low postoperative pain
and curtailed recovery time while obviating the need for
a large transabdominal approach which was the bane of
the Stoppa’s approach. Despite these advantages many
practicing surgeons are still reluctant to adopt this
technique because of lengthy operative time and the long
learning curve for this procedure.
Mean operative time in the first 50 patients of TEP
repair varied from 35 to 95 min (average 45.6) for uni-
lateral and 50 to 100 (average 69.2 min). The operative
time after 50 patients was 29–45 min (average 31.2 min)
and 37–50 min (average 42.1 min) for unilateral and
bilateral hernia, respectively. The reduction in the
operative time with gaining of experience is thus obvi-
ous. But the time was still significantly more than that
taken to do a APP repair, both in unilateral and bilateral
hernias,18.8 and 31.7 min, respectively (Table 2). Inter-
estingly a number of recent studies have shown that TEP
may actually take less time as compared to Lichten-
stein’s repair [1,5]. In all these studies the time cited has
been 34–99 min for Lichtenstein repair [5]. To us this
time for open repairs appears to be on the higher side.
Our own time for APP repair averages 18.8 and
31.7 min. But most of the studies to date still show either
equal operative time for both the procedures or a longer
operative time period for TEP repair [6,7] as compared
to the open hernioplasty.
There were no operative complications in any of our
patients of APP or TEP repair, although literature re-
ports 1.2–5.6% incidences of operative complications in
TEP repairs. The most common is the urinary bladder
injury especially in patients with previous suprapubic
surgery, followed by bowel injury and major vessel
injuries [8]. Pneumoperiteneum as a result of obvious or
hidden peritoneal tears has been reported in as many as
18–50% of TEP repairs [12]. We had an incidence of
41.7% tears, which was significant as compared to the
APP group. The tear included both obvious tears and
unrecognizable tears where the only indication that
peritoneal breach has occurred was a pueumoperitone-
um developing during the TEP procedure. The tears
were more prone to develop in long standing large size
inguinal hernias extending into the scortum where sac
retraction was difficult and tedious. The management of
these peritoneal tears is controversial. Stitching these
tears with intracorporeal suturing or even clips has been
recommended [9]. We have always left the obvious
peritoneal tears of less than 1 cm unstitched, as has been
done by Voeller et al. [10]. A precaution which we took
was ensuring a 20% head low position for first 24 h
postoperatively to keep the bowel away from the mesh
by gravity.
Postoperative preperitoneal or scrotal haematomas
have been reported between 0.4 and 8% after TEP repair
[11,12] and 0.6 and 7.4% in open repair [13,14]. The
incidence has decreased with the stitching of Transver-
salis fascia and the use of scrotal drains by a few [13]. We
had four patients with preperitoneal haematomas in
TEP and one patient had a subcutaneous haemotoma
after APP. This difference did not assume significant
proportions. All these haematomas resolved over a
period of time.
189
Postoperative urinary retention has been seen in 2–
10.9% after TEP and in 1.1% after open repair [15]. The
higher rate in TEP may be attributed to the preperito-
neal dissection near the bladder and the general anes-
thesia with neuromuscular paralysis in the TEP group.
Two of our patients required postoperative catheteriza-
tion and both were above 60 years, and had prostato-
megaly.
Postoperative chronic, somatic and neuralgic pain
have been reported as 0–28.7% after TEP and 3–36.7%
after open repair [16] and numbness as up to 35.8% after
open repair, and the numbness in TEP repair has been
reported as 2.8% [17]. One patient had scar pain and one
had neuralgia along the lateral aspect of the thigh in the
TEP group while significantly more patients in the APP
group had scar pain (P<0.05) while the incidence of
neuralgia was not significantly different. But none of
these patients in either group had any pain beyond
1 month postoperative. Neumayer and co-workers [18]
also report that the incidence of the pain on the day of
the surgery and at 2 weeks after laparoscopic repair is
less as compared to the open repair.
The recurrence rate for open preperitoneal repair has
been quoted as 1.1–12.0% [13]. We had two patients
with recurrence in the APP group and in one of them
this occurred on the first postoperative day because of
mesh migration. The recurrence rate after TEP repair on
the other hand has been reported as varying from 0 to
20% although the majority reported it as 1–3% [13].
Neumayer and co-workers [18] have reported a lesser
incidence of recurrance after open repair, 49% as com-
pared to 10.1% in the laparoscopic group. We had four
(3.33%) recurrences noticed within 48–72 h and was due
to mesh migration in direct inguinal hernia. All recur-
rences in the TEP group occurred in the first 50 patients.
A 1 year follow-up seems to be enough for patients with
preperitoneal mesh placement because all recurrences
are because of technical defects, in the form of inade-
quate myopectineal orifice clearance or inadequate mesh
size and occur within the first year and are operator
dependent [18]. In contrast non-mesh hernioplasty
recurrences can occur up to 5 years or even later and
have been reported as 3–36.8% [6]. This difference is
obviously because tension-free mesh reinforcement of
the groin takes care of all existing and potential inguinal
hernia orifices and avoids the trauma associated with
conventional open surgical repair thus safeguarding the
healthy tissue structures in the area.
Regarding serious postoperative wound infection the
conventional anterior versus lap hernia repair trial per-
formed in the Netherlands in 1997 [19] identified
advantages for patients undergoing lap procedure com-
pared with those receiving open repair hematoma/sero-
ma formation occurred with almost equal frequency in
both TEP and TAPP groups. Such patients responded to
evacuation of haematoma or aspiration of seroma and
none required reoperation. Wound infection following
lap repair has been variously reported as 0–2.8% [7]. In
our studies, one patient each developed infection in the
TEP and APP group. The preperitoneal mesh abscess in
the TEP group was managed by aspiration and instil-
lation of local metronidazole and povidone iodine.
There were no port site infections. The wound infection
in the APP group responded to conservative therapy.
Only 4 out of 120 patients in TEP group required
conversion. In three cases it was due to an accidental
tear of the peritoneum and in the other it was an
inability in developing the preperitoneal space as the
patient had dense adhesions in the bladder area fol-
lowing a previous suprapubic cystolithotomy. Our re-
sults can be compared with those of others showing
conversion rates between 0.3 and 1.6% [6]. It has been
pointed out that laparoscopic approaches are superior to
anterior suture repairs but there is no significant differ-
ence in recurrences when open or laparoscopic mesh
repairs are compared [19].
The results also showed significantly less hospital-
ization time and early return to work in all patients
undergoing TEP repair as compared to APP repair. This
is again in agreement with the results of others [13]. It
may be pointed out that our patients being mostly from
village background prefer to stay longer in the hospital
despite being advised to go.
The operating time for APP repair of unilateral and
bilateral hernias is significantly less as compared to the
TEP repair. As we gain more experience with TEP the
operating time of TEP may decrease further but it may
be difficult to achieve the operating time equivalent to
those of APP. But, on the other hand, a patient under-
going TEP repair will have a shorter hospital stay, will
return to work earlier and will have less postoperative
pain. Not withstanding these advantages the extended
operative time, and unusual major complications are
probably the main deterrent for TEP becoming the gold
standard for groin hernia repair.
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