Hernia DOI 10.1007/s10029-014-1246-4

ORIGINAL ARTICLE

A comparative study of single incision versus conventional laparoscopic inguinal hernia repair G. P. C. Yang • K. L. M. Tung

Received: 31 August 2013 / Accepted: 28 March 2014 Ó Springer-Verlag France 2014

Abstract Background Over the past years, safety and feasibility of conventional laparoscopic inguinal hernia repair was well established. However, conventional laparoscopic hernia repair (CL) usually requires three working ports ranging from 5 to 10 mm, and each increasing port is associated with possible increasing morbidity and pain related to ports. This has led to the development of single incision laparoscopic hernia repair (SIL) which can further reduce the port-related morbidities and improve cosmetic outcomes. The aim of the study was to evaluate the safety and feasibility of SIL using both transabdominal preperitoneal (TAPP) and totally preperitoneal (TEP) approaches and compare the patients’ wound satisfaction between the two groups. Methods This is a retrospective review of prospectively collected data. We analyzed the results of patients who underwent either CL or SIL for inguinal hernia between January 2011 and July 2012 in Pamela Youde Nethersole Eastern Hospital. Patients’ demographic details, type of hernia, operative time, mesh used, and post-operative complications were compared. A telephone survey was also conducted to evaluate patients’ subjective wound satisfaction. Results In total, 32 SIL and 35 CL procedures were performed in this period. The two groups were matched for age, sex, type of hernia and ASA grading. The mean operative time was significantly shorter in the CL group (52.6 vs. 62.6 min, p = 0.02). All SIL procedures were completed successfully without conversion to CL or open repair and post-operative complications such as wound infection, seroma, recurrence and chronic pain were also G. P. C. Yang  K. L. M. Tung (&) Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China e-mail: [email protected]

comparable between the two groups. As for the telephone survey, SIL groups’ wound is less obvious and less detectable by others as compared to CL, but on the whole both groups of patients are very satisfied with the wound outcomes. All the SIL groups would continue with their decision on SIL and 60 % of CL group would choose SIL if they had to go back in time. Conclusion Our results have shown that in experienced hands, SIL is feasible and as safe as CL. Further randomized trials should be performed to evaluate the clinical application of single incision TEP and TAPP. Keywords Laparoscopic inguinal hernia repair  Single incision laparoscopic inguinal hernia repair  Transabdominal preperitoneal approach  Totall preperitoneal approach

Introduction Inguinal hernia is one of the most common surgical diseases. Over the past years, its surgical treatments have evolved a long way, from tissue repair employing Bassini or Shouldice repairs to tension-free repair as introduced by Lichtenstein in 1987. The initial focus on a successful repair was to achieve a low recurrence rate which has already been accomplished by various repair techniques has now shifted to other aspects such as avoidance of chronic pain, early return to normal activity and better cosmetic outcomes. Since the first laparoscopic herniorrhaphy was performed by Ger in 1991, it becomes one of the most commonly performed minimally invasive surgical procedures [1–3]. Not only having comparable recurrence rate as open counterpart, it was also praised for having less post-operative pain, a shorter recovery period, earlier

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return to normal daily activities and work, and better cosmetic results [4]. However, conventional laparoscopic hernia repair (CL) usually requires three working ports ranging 5–10 mm, and each increasing port is associated with possible increasing morbidity and pain related to ports [5]. This has led to the development of single incision laparoscopic (SIL) hernia repair which can further reduce the port-related morbidities and improve cosmetic outcomes [6]. We have previously reported our cohort series of 15 cases of inguinal hernias which were all successfully performed using single incision techniques [7]. And the aim of this study was to evaluate the safety and feasibility of SIL using both transabdominal preperitoneal (TAPP) and totally preperitoneal (TEP) approaches and compare the patients’ wound satisfaction between the two groups.

Patients and methods This is a retrospective analysis of prospectively collected data on consecutive patients who underwent either elective CL or SIL for inguinal hernia from January 2011 to July 2012 in Pamela Youde Nethersole Eastern Hospital. Full consent was obtained from all patients, and the nature and potential complications of the surgery were clearly explained to all. All operations were performed by surgeons specializing in laparoscopic hernia repair who had experience in single-port surgery. Prophylactic antibiotic (Cefuroxime 1.5 g) was given on induction for all patients. Under general anesthesia, the patients were placed in supine position, and a Foley catheter was inserted preoperatively.

Operative techniques Conventional 3-port laparoscopic TEP hernioplasty (CL group) The operating surgeon stands on the opposite side of the hernia. A 5-mm incision is first made two fingerbreadths above the pubic symphysis for insertion of the Veress needle into the preperitoneal space and then insufflated with 1 L of CO2. A 10 mm Hasson trocar is then introduced into the preperitoneal space through a subumbilical incision. The preperitoneal space is insufflated with CO2 to a pressure of 12 mmHg, and a 0° laparoscope is then inserted. The patient is then placed in a Trendelenburg position. Under direct vision, Veress needle is removed and replaced with 5-mm ports. Another 5-mm working port is placed in the lower abdomen opposite to the side of hernia. Two graspers are passed through the two lower ports for dissection. Dissection of the preperitoneal space is continued to the pubic bone inferomedially and psoas muscle inferolaterally. Any direct

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sac found is reduced, and the spermatic cord is dissected to identify any indirect sac. If present, the indirect sac is ligated using endo-tie and transected distally. Parietalization of the peritoneum is then performed. A synthetic mesh is placed at the preperitoneal space which covers up the site of direct, indirect, femoral and obturator hernias. After adequately spreading the mesh, the preperitoneal space is deflated. Single incision laparoscopic hernioplasty (SIL group) For both TAPP and TEP groups, we used a 0o flexible 5-mm laparoscope (Olympus, Center Valley, USA). Both SILS port (Covidien, Dublin, Ireland; United States Surgical, Mansfield, USA) and TriPort? (Olympus; Advance Surgical Concepts, Bray, Ireland) were used in this series. No other specialized instruments were used. As in conventional laparoscopic surgery, laparoscopic dissectors, scissors and graspers were used. A 10-by-15 cm Parietex ADP2 mesh (Sofradim, Tr´evoux, France; Covidien) was used for groin repair in all cases. As this is an anatomical mesh, no mesh fixation was used in this series. The surgeon’s preference determined the type of single port used and the repair approach (TAPP or TEP) performed. For the TAPP approach, we preferred SILS ports, and for the TEP approach, we preferred TriPort?. For the TAPP approach, a 2.5-cm transumbilical incision was made. Pneumoperitoneum with carbon dioxide at a pressure of 10–12 mm H2O was created. After diagnostic laparoscopy, the peritoneum over the side of inguinal hernia was incised, the preperitoneal plane was opened. The hernia sac was isolated and then either reduced as a whole, or ligated at its proximal end and transected distally. Hernia mesh was laid, and the peritoneum was then closed with AbsorbaTack (Covidien; United States Surgical). Pneumoperitoneum was released. The umbilical fascia wound was closed with PDS (polydioxanone) I sutures (Ethicon, Sommerville, USA), and the skin was closed with subcuticular polypropylene sutures (Ethicon). For TEP, a 1.5-cm transverse subumbilical incision was created. The open method was employed for access to the preperitoneal plane through an incision made on the anterior fascia of the rectus sheath. Blunt dissection of the preperitoneal plane was performed with the index finger, and the TriPort1 was inserted into the preperitoneal plane. Pneumopreperitoneum with carbon dioxide at a pressure of 10–12 mm H2O was created. The preperitoneal plane was dissected open. The hernial sac was identified and isolated. It was either reduced as a whole, or ligated at its proximal end and transected distally. The hernia mesh was then laid in place. Control release of pneumopreperitoneum was carried out. The anterior fascia wound was closed with PDS I sutures, and the skin wound was closed with subcuticular polypropylene sutures.

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Postoperative care and follow-up The surgical team as well as a specialist wound nurse followed up with all patients. Any wound infection, postoperative complication and recurrence were recorded. At 12 months’ time, a telephone survey was conducted by our wound specialist Mr. Ho Chi Wai. During the interview, a list of six questions was asked. And a scoring system from 1 to 5 as shown below was used. (1) (2) (3) (4) (5) (6)

How well can you visually detect your surgical wound?: 1 (not at all)—5 (most obvious) How obvious can other people detect your surgical wound?: 1 (not at all)—5 (easily) Do you have any wound discomfort?: 1 (none)—5 (very discomfort) Do you find your surgical wound disturbing/ incapacitating?: 1 (normal)—5 (very debilitating) How satisfy are you with your surgical wounds?: 1 (happy)—5 (very unhappy) Would you like to have conventional or single incision laparoscopic hernia repair done if you can choose once again?: 1 (SILS)—2 (conventional)

Table 1 Preoperative patients’ characteristics SIL (N = 32)

CL (N = 35)

p value

Age (years)

61.7 (28–88)

61.5 (38–81)

0.9*

Sex (M/F)

29/3

32/3

0.7#

Right

14

14

0.26#

Left

12

7

Bilateral

6

14

Direct

10

12

Indirect

19

20

Other (obturator/femoral)

3

0

32 0

32 3

Side of hernia

Type of hernia

ASA 1 and 2 ASA 3 and 4

0.33#

0.7#

ASA American Society of Anesthesiologists * Student’s t test,

#

Chi-square test

Table 2 Operative details SIL (N = 32)

CL (N = 35)

p value

66.6

52.6

0.02 *

SILS

22





Triport

10 0.7#

OT time (min) Port used

Measured outcomes In addition to patient demographic data, we recorded the type of surgery performed (TAPP or TEP), hernia type, the side of the hernia, operative time and post-operative complications. A telephone survey of 6 questions was also conducted to evaluate patients’ subjective wound satisfaction. Statistical analysis SPSS software (Windows version 13, SPSS Inc., Chicago, IL, USA) was employed for data analysis, and Chi-square test, Fisher exact test or Mann–Whitney U test was used where appreciate. A p value of 0.05 or below was considered to be significant.

Results Between January 2011 and July 2012, we performed altogether 32 SIL and 35 CL procedures. The two groups were matched for age, sex, type of hernia and ASA grading as shown in Table 1. Operative details are listed in Table 2. The mean operative time was significantly shorter in the CL group (52.6 vs. 62.6 min, p = 0.02). All SIL procedures were completed successfully without conversion to CL or open repair. No additional port was required in the SIL group (Table 3). Post-operative complications such as wound infection, haematoma or chronic pain were not

Mesh used Parietex

25

24

Ultrapro

7

11

TEP

6

34

TAPP

26

Type of repair

* Mann–Whitney U test,

0.001#

1 #

Chi-square test

Table 3 Postoperative result SIL (N = 32)

CL (N = 35)

p value

Conversion

0

0



Infection

0

0



Haematoma

0

0



Seroma

7

5

0.4#

Recurrence

0

1

0.3#

Chronic pain

0

0



#

Fisher exact test

detected in both groups. Several small seroma were reported in both groups (SIL 7, CL 5, p = 0.4), and all of them were resolved with conservative treatment. Only a single case in the CL group developed recurrence. As for the telephone survey, the completion rates for both groups were over 80 %. Details of the score are shown in Table 4. Patients in CL group found their surgical wound to be more

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Hernia Table 4 Telephone survey results Question

SIL

CL

p value

How well can you visually detect your wound?

1.23

1.43

0.336#

How obvious can other people detect your wounds?

1

1.37

0.04#

Do you have any wound discomfort? Do you find your wound disturbing or debilitating?

1.15 1

1.26 1

0.55# 0

How satisfy are you with your wound?

1.08

1.26

0.625#

Would you like to have conventional or single incision laparoscopic hernia repair done if you can choose once again?

100 %

100 %



#

Fisher exact test

obvious than SIL group although the result is not statistically significant (average score CL 1.43, SIL 1.23, p value 0.336). SIL groups’ surgical wound is less detectable by others as compared to CL groups (p value 0.04). Both groups of patients are very satisfied with their wound with minimal discomfort. When going back in time, all the patients in SIL group would continue their decision with SIL, and 60 % of CL group of patients would choose SIL instead.

Discussion Single incision laparoscopic surgery is developed in an attempt to further minimize the wound access trauma by reducing the number of puncture wounds on the abdominal wall. Randomized comparative studies have been performed for single incision laparoscopic cholecystectomy and colectomy [8, 9]. Majority of the studies showed improved in cosmetic result; however, pain score varies from the types of surgeries with higher pain score recorded in cholecystectomy and lower pain score in colectomy patients. In this comparative study against conventional laparoscopic hernia repair, it showed that the SIL group required longer operative time. The complication rates were comparable except for the statistically insignificant seroma rate. The true value of SIL in hernia repair may be of the final cosmetic result. SIL was very well accepted by the patients as shown in our post-operative telephone survey which reveals a higher satisfaction and cosmetic score. Nevertheless, SIL groin hernia repair is technically demanding with a steep learning curve. Till now, there were only case reports and small case series on SIL groin hernia repair in the world since the first case was performed in 2009. Although all of them reported that SIL hernia repair was technically feasible and safe to perform, yet

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many difficulties were encountered due to confined operating space, in-line positioning of laparoscope, close proximity of working instruments with limited triangulation, limited range of motion of laparoscope and instruments, and decreased number of ports [10–12]. As a result, we believed that it should be done by a senior laparoscopic surgeon who has mastered the skill of single incision surgery. The patients should be selected; those with inguinoscrotal hernia and high BMI ratio should be avoided as the technical difficulties increase further especially for those surgeons who are at the learning curve period for SIL groin hernia repair. There are many different kinds of specially designed single incision access ports available in the market. Those used in this study are SILS and Triport?. These ports do have their individual distinct characteristics. Compared to Triport?, the SILS port does have individual working channels for each instrument so the clashing through the single wound can be minimized and parallel dissection can be performed better. For Triport?, with its introducer it can safely pass through a smaller wound size even down to 1.5 cm and does not require any forceful introduction. Which one works better basically depends on each surgeon’s individual preference. Regarding the benefit of SIL hernia repair, the greatest benefit may truly be the better cosmetic result. Therefore in order to maximize this benefit, we advocate the use of transumbilical SIL TAPP so that the wound can be concealed within the umbilicus. Otherwise with the TEP approach, one still ends up with a single visible subumbilical wound. However, early series reported higher complication rates with the umbilical wound including infection and incisional hernia occurrence [13, 14]. However in our experience, this has not occurred in this series of patients. This may be due to the fact that PDS suture was used to meticulously close the umbilical fascial defect instead of Vicryl suture as used by many of the authors. SIL groin hernia repair offers better cosmetic results with slightly longer operative time compared to conventional laparoscopic groin hernia repair. However, this approach is technically demanding and should be reserved for experienced single incision hernia surgeons. Further studies are required to delineate its true potential and value in laparoscopic groin hernia repair. Conflict on interest None.

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A comparative study of single incision versus conventional laparoscopic inguinal hernia repair.

Over the past years, safety and feasibility of conventional laparoscopic inguinal hernia repair was well established. However, conventional laparoscop...
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