Laparoscopic TEP inguinal hernia repair - Early results
Laparoscopic inguinal hernia repair: a NICE operation
A.M. PULLYBLANK, L. CARNEY, F. BRADDON* and A.R. DIXON
Department of General Surgery and Information Systems* Frenchay Hospital, Bristol, BS16 1LE, UK
Keywords: laparoscopy, hernia, extra-peritoneal repair, NICE
Published evidence comparing laparoscopic and open herniorraphy is controversial. NICE recommends that open techniques are used for first time repairs and that TEP be considered for bilateral/recurrent repairs undertaken in specialist units. We report a consecutive series of 224 patients undergoing 268 TEP repairs between 1996 and 2001. Operating time, complications, return to normal activity/full time employment and recurrence were examined. The median operating time was 30 minutes. There was one conversion. Ninety four percent of patients drove on the third post-operative day. The median time to normal activity was 4 days (1-10 days). The median time to return to professional employment in 82 patients was 3 days (range 2-9 days). Four patients (1.7%) had self-limiting minor groin pain. There were 3 recurrences (1.4%) and none since altering the surgical technique to use a larger anchored mesh. We have demonstrated TEP to be an easily learnt, safe, effective technique with low morbidity, and with sufficient experience, takes no longer than an open repair. It can be performed at little increased cost and restores selected patients to an early return to full-time employment. We believe that the choice between open and laparoscopic repair is a subjective decision for patient and surgeon
J.R.Coll.Edinb., 47, August 2002, 630- 633
With approximately ten per 10,000 of the UK population having a groin hernia, herniorraphy is one of the commonest operations carried out.1 Open repair is considered the operation of choice because it is perceived to be a safe, easy operation, which can be performed under local anaesthesia. 2 In comparison with open repair, laparoscopic repair is associated with less post-operative pain and an earlier return to normal activities.3-7 Unlike cholecystectomy; laparoscopic herniorraphy has failed to capture the imagination of surgeons. This is surprising since no additional skills are necessary and we perceive the learning curve to be no longer than that of the more popular cholecystectomy or a properly executed open repair. Laparoscopic repair can be either transabdominal properitoneal (TAPP) or totally extraperitoneal (TEP). Although TAPP is said to be easier to learn, serious complications have been reported. TEP is safer than TAPP and has a shorter operative time and earlier return to work than open repair.8,9
NICE is charged with providing the NHS in England and Wales with independent advice on the efficiency and cost effectiveness of selected health technologies and procedures. NICE bases its guidance on appraisals conducted by external agencies, which are then reviewed by the Institute’s standing Appraisal Committee. The advice on hernia repair has recently been published on the Internet (www.nice.org.uk)10. NICE concludes that first time hernias of the groin ought to have open repairs and that laparoscopic TEP repair should only be considered for bilateral and recurrent hernias and be performed in specialist units. We report our experience of 224 consecutive-patients undergoing a minimal cost TEP repair focusing on complications, recovery time and recurrence rate.
A series of 224 consecutive patients underwent 268 elective TEP repairs between January 1995 and January 2001. Data were collected prospectively on length of procedure, hospital stay and return to normal activity. Patients were advised that they could drive when comfortable, return to sedentary jobs from day three onwards and manual jobs/physical training after 10 days. All were reviewed at 4 weeks and complications recorded.
Surgery was performed under general anaesthesia. A 15mm incision below the umbilicus is continued through the anterior rectus sheath on the operative side. The rectus muscle is retracted laterally and a 10mm camera/insufflation port placed behind this muscle. The surgeon stands on the side opposite the hernia. A 30-degree laparoscope is used to dissect the pre-peritoneal space. A 5mm operating port is placed in the midline midway between the symphysis pubis and the umbilicus and after further development of the pre-peritoneal space; the hernia sac is identified and reduced. In indirect hernias we continue the dissection posterior to the internal ring for no more than 3-4 cms. It is the senior authors preference to hold the camera whilst carrying out the dissection as it is felt that this improves his spatial abilities. Dissection is often aided by the placement of a hand over the deep inguinal ring, which provides some counter traction to stop the cord structures sliding away. It is only the largest indirect sacs that require an additional 5mm operating port placed just above the pubis in the midline. In these cases, we have transected the sac leaving the distal sac in-situ and closed the proximal defect with an endoloop. A 15x 10cm polypropylene mesh is passed through the 10mm port, having been folded/pleated x2 and held in place with a nylon running suture. Once the mesh is in a satisfactory position it is anchored using titanium tacks (Origin, Tyco Healthcare) into the pubic bone and Coopers ligament. The running stitch is removed and the mesh unfolded. Further tacks are placed in the muscle layers anteriorly. To avoid potential nerve entrapment, none are directed laterally, into or below the iliopubic tract. After releasing the ‘ pneumoperitoneum’, 30 mls of 0.5% bupivacaine is injected through and around the port sites.
Two hundred and sixty-eight pre-peritoneal repairs were performed in 224 patients (17 females); the median age was 42 (range 24-76 yrs). Fifty-four repairs were bilateral and 16 were recurrent. In all cases, the senior author performed or supervised the procedure. A higher surgical trainee performed 78 of the repairs. The median operation time was 30 minutes (range 8-110) minutes. Twenty-four repairs were planned as day cases; 23 were discharged the same day. One hundred and ninety patients were admitted overnight whilst 11 stayed two nights in hospital. Return to normal activity was rapid with only a minority (5%) not driving by the third day. The median time to normal physical activity was 5 days (range 2-10 days). The median time to return to work in 82 patients, engaged in professional employment, was 3 days (2-9 days). Although advised they could return to work after 10 days, all manual workers were ‘signed off’ until outpatient review. Three patients resumed golf on the second post-operative day and one professional rugby on day 15.
No patient died and there were no major complications. In one patient with an appendicectomy scar, a right-sided hernia was converted to an open procedure after creating an‘pneumoperitoneum’ that was uncontrolled by a veres needle placed in the left upper quadrant. The repair was completed by open placement/anchoring of the mesh in the dissected space. There were five minor complications (1.8%) including two cases of meralgia paraesthetica suggestive of lateral cutaneous nerve irritation; both settled within two weeks. Two patients developed severe, transitory groin pain at 6 and 9 weeks post surgery, one of which subsequently claimed to have become impotent. One patient developed acute retention. Two recurrences occurred within 4 weeks and one at 20 months -1.1% recurrence rate per repair and 1.4% per patient. These recurrences were seen in two patients with direct and one with indirect hernias. Re-operation demonstrated mesh migration in the direct cases; both occurred early in the series when our policy was not to anchor the mesh. The third patient had a 6 x 5cm mesh and an indirect recurrence. There have been no recurrences since 1997 when as a result of these experiences the technique was modified to use an anchored 15 x 10cm mesh.
Our results compare favourably with previous reports of TEP repair. The median operating time of 30 minutes comparable to that described by others, and incorporates both the ‘learning curve’ and teaching cases. 9, 11,12 Meta-analysis of randomised controlled trials of laparoscopic versus conventional repair demonstrates an earlier return to work as being one of the main advantages of laparoscopic repair; our series supports this.7 There were few complications. Early neuralgia, either in the inguinoscrotal region or lateral cutaneous nerve has been noted by others and usually resolves spontaneously.11, 13-15 Like previous authors we encountered difficulty in patients with previous surgery.13-15 We no longer advocate laparoscope dissection for right-sided hernias in patients who have had a previous appendicectomy for fear of tearing the peritoneum and obliterating the operative space. This potential problem can be overcome using a combination of balloon dissection and an inflatable ‘bridge’ (Tyco Healthcare); the latter maintains the operative field if the peritoneum is breached. We recognise that our data is at odds with published trials in that none of our patients have developed a seroma, which is generally reported around 10%.18 We are unable to offer any explanation for this finding other than we try to limit our dissection to the hernia sac and avoid the lymphatic and iliac vessels.
The true test of any hernia repair is the recurrence rate. Most recurrences after laparoscopic repair are probably due to technical errors and occur early. Two of ours were obvious at four weeks. Our recurrence rate of 1.1% per hernia repaired (1.4%/patient) compares favourably with a 1-year recurrence of 0.5%9 and 1.69-% at 38 months.14 There are few data on long-term follow-up but a recent randomised trial of TAPP versus Shouldice repair demonstrated no significant difference between the two procedures.17 However, Knook et al (1999) reported a recurrence rate of 3.2% for primary hernias, rising to an unacceptable 20% for recurrent hernias repaired by TEP.15 These authors chose not to fix the mesh, relying on intraabdominal pressure alone, supporting our own experience that it is necessary to fix the mesh. Whilst accepting that fixation is controversial and largely unproven our recommendation is based solely on our own experience. When developing the technique, the senior author reasoned that fixation was unnecessary and carried this through to the early part of this series. Several direct recurrences have developed in other series, re-operation demonstrating mesh migration in an inferior direction in each case. (Espiner’s personal communication) We also have personal knowledge of other surgeons in our region who have documented similar recurrences yet still continue not to fix the mesh.
A recent systematic review of 34 suitable trials involving 6804 patients has confirmed laparoscopic repair is associated with less post-operative pain and a more rapid return to normal activities.18 Whilst operating times were longer, length of hospital-stay did not differ significantly between groups. Whilst operative complications were uncommon for both groups, visceral (usually bladder) and vascular injuries were more frequent in the laparoscopic group. However, all followed TAPP repair. Overall, recurrences did not differ between groups.
Despite the existence of several operative techniques and the potential advantage offered, most surgeons and NICE prefer an open tension-free mesh.2, 18 Many surgeons site cost as a part of their reasoning. Using laparoscopic dissection as described and reusable ports, instead of commercially available balloon systems, the cost of repair can be reduced to an acceptable level, approximately £70 more than a standard open repair or only slightly more than when using a combined plug/mesh. Although only 10% of our cases were performed as day cases (PM operating list) the vast majority (85%) involved only an overnight stay. These figures compare favourably to the average stay of 2.4 days for primary repair posted on the NICE website (www.nice.org.uk). We believe that these costs are more than offset by the benefits accrued by our patients and the 19% of patients who returned to full-time employment after three days.
So why do surgeons prefer the open approach? Whilst the adverse publicity associated with the development of laparoscopic cholecystectomy may have deterred some surgeons from tackling the learning curve associated with inguinal herniorraphy it did not prevent surgeons from performing cholecystectomies and more technically demanding fundoplication! The latter has also been associated with visceral and vascular injury, which on occasion has proved fatal. Whilst accepting that some surgeons may perceive or find the operation difficult and that many have failed to learn the technique returning to open surgery, examination of the TEP learning curve demonstrates that, even allowing for increased operating time and complications early in the learning curve, recurrence and morbidity rates are comparable with other open and laparoscopic techniques.12, 14 We have demonstrated-that supervised higher surgical trainees working in a unit not dedicated to laparoscopic surgery can quickly pick up the nuances of the surgical approach and safely carry out the technique. If we had followed the NICE recommendation10 of reserving TEP for bilateral and recurrent hernias we would have performed only 11 cases/year, a number we consider insufficient for learning, maintaing/improving and teaching the technique.10
The median age of our patients demonstrates a degree of selection bias. The main advantage of laparoscopic surgery lies in an earlier return to work and hence our data are skewed towards a younger professional/physically active population in whom this was considered important. We would advocate that there is a place for both open and laparoscopic repair in surgical practice and for the surgeon who is already experienced at laparoscopic cholecystectomy, the learning curve should not be a deterrent to becoming proficient in TEP hernia repair.
Both from an evidence base and clinical points of view, TEP appears to be superior to open repair and the preferred method, therefore, is a subjective decision for the patient and surgeon to make together. As a result of the NICE guidance our Trust’s National Strategies Implementation Committee has requested our comments on the guidelines and their implications for our Trust. However, we are encouraged by NICEs introductory statement that their guidance does not override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with that patient.
Dr George Fielding, Brisbane, Australia taught the senior author the technique of laparoscopic pre-peritoneal dissection. Further modifications followed discussions with Mr Harry Espiner, Bristol, UK
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Copyright: 20 April 2002
Correspondence: Miss A.M. Pullyblank, 17 Fremantle Road, Cotham, Bristol, BS6 5SY