Original Article
Single site and conventional totally extraperitoneal techniques for uncomplicated inguinal hernia repair: A comparative study Felipe Brandão Corrêa de Araújo, Eduardo Simão Starling, Marco Maricevich1, Marcos Tobias-Machado Urologic Department, Faculdade de Medicina do ABC, Santo Andre, SP Brazil, 1General Surgery Department, Mayo Clinic, Rochester, Minnesota, United States Address for Correspondence: Dr. Felipe Brandão Corrêa de Araújo, 62/1902 Evaristo da Veiga street, Casa Amarela, CEP: 52070-100, Recife, Brazil. E-mail: [email protected]
Abstract OBJECTIVE: To demonstrate the feasibility of endoscopic extraperitoneal single site (EESS) inguinal hernia repair and compare it outcomes with the conventional totally extraperitoneal (TEP) technique. BACKGROUND: TEP inguinal hernia repair is a widely accepted alternative to conventional open technique with several perioperative advantages. Transumbilical laparoendoscopic singlesite surgery (LESS) is an emerging approach and has been reported for a number of surgical procedures with superior aesthetic results but other advantages need to be proven. PATIENTS AND METHODS: Thirtyeight uncomplicated inguinal hernias were repaired by EESS approach between January 2010 and January 2011. All procedures were performed through a 25 cm infraumbilical incision using the Alexis wound retractor attached to a surgical glove and three trocars. Body mass index, age, operative time, blood loss, complications, conversion rate, analgesia requirement, hospital stay, return to normal activities and patient satisfaction with aesthetic results were analysed and compared with the last 38 matched-pair group of patients who underwent a conventional TEP inguinal hernia repair by the same surgeon. RESULTS: All procedures were performed successfully with no conversion. In both unilateral and bilateral EESS inguinal repairs, the mean operative time was longer than conventional TEP (55± 20 vs. 40± 15 min, P = 0.049 and 70± 15 vs. 55± 10 min, P = 0.014). Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.141521
Aesthetic result was superior in the EESS group (2.88± 0.43 vs. 2.79± 0.51, P = 0.042). There was no difference between the two approaches regarding blood loss, complications, hospital stay, time until returns to normal activities and analgesic requirement. CONCLUSION: EESS inguinal hernia repair is safe and effective, with superior cosmetic results in the treatment of uncomplicated inguinal hernias. Other advantages of this new technique still need to be proven. Key words: Inguinal hernia, laparoscopic, single site surgery, LESS
INTRODUCTION The first description of laparoscopic inguinal hernia repair was in the early 1990s. This approach widely accepted is an alternative to conventional treatment with several advantages: reduction of postoperative pain, a short recovery period, extraperitoneal mesh placement and the possibility to treat simultaneously a contra lateral unexpected hernia.[1,2] The laparoscopic technique typically involves three ports ranging from 5 to 10 mm. Every incision and trocar placement poses a risk of bleeding, organ damage, incisional hernia and less desirable cosmetic effect. Transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair have become the most common techniques to treat inguinal hernia. TEP approach has some advantages over TAPP approach, but has proved to be more technically demanding.[3,4] Transumbilical laparoendoscopic single site surgery (LESS) is an emerging approach and has been reported for a number of surgical procedures with superior aesthetic results but other advantages need to be proven.[5-9]
Journal of Minimal Access Surgery | October-December 2014 | Volume 10 | Issue 4
197
Araújo, et al.: Laparoendoscopic single site inguinal hernia repair
There are few studies demonstrating the feasibility of extraperitoneal single site (EESS) in the treatment of inguinal hernia[3,10-15] and there are only two papers comparing single incision and conventional TEP inguinal hernia repair.[16,17] The aim of this study is to report our initial experience with EESS inguinal hernia repair comparing outcomes with a conventional laparoscopic TEP technique control group of patients.
PATIENTS AND METHODS In the period between January 2010 and January 2011, 26 consecutive men with 38 uncomplicated inguinal hernias were included in this study. Diagnosis was made by physical examination or by imaging (ultrasound or computed tomography [CT] scan) in few cases when there was un-certainty. A total of 12 patients had bilateral and 14 had unilateral hernias. Patients with incarcerated, strangulated or recurrent hernia were excluded. After discussion, risks and benefits of EESS inguinal repair, including the possibility of placing other ports or conversion to conventional TEP approach, an informed consent was signed by every patient. Comparative Parameters Evaluated Age, hernia characteristics, body mass index (BMI), operative time, blood loss, complications, conversion rate, days on oral pain medication (minor analgesics) after discharge, hospital stay, return to normal activities and patient satisfaction with aesthetic results were prospectively analysed and compared with matched-pair group of patients who underwent conventional TEP inguinal hernia repair by the same surgeon during October 2008 to December 2009. The data from the matched-pair control group was collected from a prospectively database. In both groups, a scale was used to access satisfaction with the cosmetic results at 3 months post-operatively. On this scale, patients reported subjectively if they were satisfied (3 points), partially satisfied (2 points) or unsatisfied (1 point). Student-t and Fisher’s exact tests were used for statistical analysis. Surgical Technique Patient is placed at supine position. A single 2.5 cm infraumbilical skin incision is used. The anterior sheath of rectus abdominal fascia is opened with a 3 cm transverse incision to gain access to pre-peritoneal space. Digital dissection and followed by balloon dilator inflation permits development of a working space and identification of important landmarks. After creation of pre-peritoneal working space, an Alexis retractor (Applied medical systems, 198
Rancho Santa Margarita, CA, USA) is placed to achieve maximum circumferential retraction of the fasciotomy and skin incision [Figure 1]. To prevent gas leak, a surgical glove is attached to the Alexis retractor and three conventional laparoscopic trocars secured through to each finger of the glove [Figure 2]. A rigid, 10 mm zero degree optic scope and two 5 mm conventional laparoscopic instruments are utilised [Figure 3]. Hernia repair is performed using a 15 × 12 cm polypropylene mesh, which is fixed by applying titanium tacks at the iliopubic tract and Cooper ligament [Figure 4]. The fascia is closed with 0 Vicryl suture and the skin is closed with subcuticular 4-0 monocryl suture. In order to achieve better ergonomics, the surgeon operated from contralateral hernia side.
RESULTS EESS group was completed successfully in all the 26 patients. No procedure was converted to conventional TEP or open procedure. Comparative demographics with EESS and conventional TEP groups are described in Table 1. The EESS and matched-pair groups were comparable regarding to BMI,
Figure 1: Alexis retractor
Table 1: Patient and hernia characteristics Variable Hernias repaired Patients Age (years) Mean±SD BMI (kg/m2) Mean±SD Hernia characteristics Bilateral Unilateral Direct Indirect
EESS
Conventional TEP
P Value
38 26
38 24
56.54±3.51
57.71±3.29
0.102
25.14±1.97
25.68±2.32
0.477
12 14 20 18
14 10 23 15
0.412 0.643
Journal of Minimal Access Surgery | October-December 2014 | Volume 10 | Issue 4
Araújo, et al.: Laparoendoscopic single site inguinal hernia repair Table 2: EESS versus conventional TEP inguinal hernia repair Variable
Figure 2: Alexis retractor and 3 conventional laparoscopic trocars
Figure 3: Dissection
Operative time (min) Mean±SD Unilateral Bilateral Blood loss (ml) Mean±SD Days of oral pain pills Mean±SD Hospital stay (hours) Mean±SD Recovery (weeks) Mean±SD Conversion Recurrence Follow-up (months) Mean±SD No. complications (%) Vascular injury Hematoma/seroma Cosmetic result (1-3) Mean±SD Satisfied Partially satisfied Unsatisfied
EESS
Conventional TEP P Value
53.9±11.6 66.79±9.73
39±9.07 53±7.89
0.049 0.014
51.54±13.9
56.25±9.35
0.335
4.65±1.7
5.38±2.6
0.271
18.23±4.94
21.25±8.29
0.123
1.73±0.83 0 0
1.96±0.91 0 0
0.147
15.5±3.38 3/11.5 1 2
25.5±4.38 3/12.5 0 3
Single site and conventional totally extraperitoneal techniques for uncomplicated inguinal hernia repair: A comparative study Felipe Brandão Corrêa de Araújo, Eduardo Simão Starling, Marco Maricevich1, Marcos Tobias-Machado Urologic Department, Faculdade de Medicina do ABC, Santo Andre, SP Brazil, 1General Surgery Department, Mayo Clinic, Rochester, Minnesota, United States Address for Correspondence: Dr. Felipe Brandão Corrêa de Araújo, 62/1902 Evaristo da Veiga street, Casa Amarela, CEP: 52070-100, Recife, Brazil. E-mail: [email protected]
Abstract OBJECTIVE: To demonstrate the feasibility of endoscopic extraperitoneal single site (EESS) inguinal hernia repair and compare it outcomes with the conventional totally extraperitoneal (TEP) technique. BACKGROUND: TEP inguinal hernia repair is a widely accepted alternative to conventional open technique with several perioperative advantages. Transumbilical laparoendoscopic singlesite surgery (LESS) is an emerging approach and has been reported for a number of surgical procedures with superior aesthetic results but other advantages need to be proven. PATIENTS AND METHODS: Thirtyeight uncomplicated inguinal hernias were repaired by EESS approach between January 2010 and January 2011. All procedures were performed through a 25 cm infraumbilical incision using the Alexis wound retractor attached to a surgical glove and three trocars. Body mass index, age, operative time, blood loss, complications, conversion rate, analgesia requirement, hospital stay, return to normal activities and patient satisfaction with aesthetic results were analysed and compared with the last 38 matched-pair group of patients who underwent a conventional TEP inguinal hernia repair by the same surgeon. RESULTS: All procedures were performed successfully with no conversion. In both unilateral and bilateral EESS inguinal repairs, the mean operative time was longer than conventional TEP (55± 20 vs. 40± 15 min, P = 0.049 and 70± 15 vs. 55± 10 min, P = 0.014). Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.141521
Aesthetic result was superior in the EESS group (2.88± 0.43 vs. 2.79± 0.51, P = 0.042). There was no difference between the two approaches regarding blood loss, complications, hospital stay, time until returns to normal activities and analgesic requirement. CONCLUSION: EESS inguinal hernia repair is safe and effective, with superior cosmetic results in the treatment of uncomplicated inguinal hernias. Other advantages of this new technique still need to be proven. Key words: Inguinal hernia, laparoscopic, single site surgery, LESS
INTRODUCTION The first description of laparoscopic inguinal hernia repair was in the early 1990s. This approach widely accepted is an alternative to conventional treatment with several advantages: reduction of postoperative pain, a short recovery period, extraperitoneal mesh placement and the possibility to treat simultaneously a contra lateral unexpected hernia.[1,2] The laparoscopic technique typically involves three ports ranging from 5 to 10 mm. Every incision and trocar placement poses a risk of bleeding, organ damage, incisional hernia and less desirable cosmetic effect. Transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair have become the most common techniques to treat inguinal hernia. TEP approach has some advantages over TAPP approach, but has proved to be more technically demanding.[3,4] Transumbilical laparoendoscopic single site surgery (LESS) is an emerging approach and has been reported for a number of surgical procedures with superior aesthetic results but other advantages need to be proven.[5-9]
Journal of Minimal Access Surgery | October-December 2014 | Volume 10 | Issue 4
197
Araújo, et al.: Laparoendoscopic single site inguinal hernia repair
There are few studies demonstrating the feasibility of extraperitoneal single site (EESS) in the treatment of inguinal hernia[3,10-15] and there are only two papers comparing single incision and conventional TEP inguinal hernia repair.[16,17] The aim of this study is to report our initial experience with EESS inguinal hernia repair comparing outcomes with a conventional laparoscopic TEP technique control group of patients.
PATIENTS AND METHODS In the period between January 2010 and January 2011, 26 consecutive men with 38 uncomplicated inguinal hernias were included in this study. Diagnosis was made by physical examination or by imaging (ultrasound or computed tomography [CT] scan) in few cases when there was un-certainty. A total of 12 patients had bilateral and 14 had unilateral hernias. Patients with incarcerated, strangulated or recurrent hernia were excluded. After discussion, risks and benefits of EESS inguinal repair, including the possibility of placing other ports or conversion to conventional TEP approach, an informed consent was signed by every patient. Comparative Parameters Evaluated Age, hernia characteristics, body mass index (BMI), operative time, blood loss, complications, conversion rate, days on oral pain medication (minor analgesics) after discharge, hospital stay, return to normal activities and patient satisfaction with aesthetic results were prospectively analysed and compared with matched-pair group of patients who underwent conventional TEP inguinal hernia repair by the same surgeon during October 2008 to December 2009. The data from the matched-pair control group was collected from a prospectively database. In both groups, a scale was used to access satisfaction with the cosmetic results at 3 months post-operatively. On this scale, patients reported subjectively if they were satisfied (3 points), partially satisfied (2 points) or unsatisfied (1 point). Student-t and Fisher’s exact tests were used for statistical analysis. Surgical Technique Patient is placed at supine position. A single 2.5 cm infraumbilical skin incision is used. The anterior sheath of rectus abdominal fascia is opened with a 3 cm transverse incision to gain access to pre-peritoneal space. Digital dissection and followed by balloon dilator inflation permits development of a working space and identification of important landmarks. After creation of pre-peritoneal working space, an Alexis retractor (Applied medical systems, 198
Rancho Santa Margarita, CA, USA) is placed to achieve maximum circumferential retraction of the fasciotomy and skin incision [Figure 1]. To prevent gas leak, a surgical glove is attached to the Alexis retractor and three conventional laparoscopic trocars secured through to each finger of the glove [Figure 2]. A rigid, 10 mm zero degree optic scope and two 5 mm conventional laparoscopic instruments are utilised [Figure 3]. Hernia repair is performed using a 15 × 12 cm polypropylene mesh, which is fixed by applying titanium tacks at the iliopubic tract and Cooper ligament [Figure 4]. The fascia is closed with 0 Vicryl suture and the skin is closed with subcuticular 4-0 monocryl suture. In order to achieve better ergonomics, the surgeon operated from contralateral hernia side.
RESULTS EESS group was completed successfully in all the 26 patients. No procedure was converted to conventional TEP or open procedure. Comparative demographics with EESS and conventional TEP groups are described in Table 1. The EESS and matched-pair groups were comparable regarding to BMI,
Figure 1: Alexis retractor
Table 1: Patient and hernia characteristics Variable Hernias repaired Patients Age (years) Mean±SD BMI (kg/m2) Mean±SD Hernia characteristics Bilateral Unilateral Direct Indirect
EESS
Conventional TEP
P Value
38 26
38 24
56.54±3.51
57.71±3.29
0.102
25.14±1.97
25.68±2.32
0.477
12 14 20 18
14 10 23 15
0.412 0.643
Journal of Minimal Access Surgery | October-December 2014 | Volume 10 | Issue 4
Araújo, et al.: Laparoendoscopic single site inguinal hernia repair Table 2: EESS versus conventional TEP inguinal hernia repair Variable
Figure 2: Alexis retractor and 3 conventional laparoscopic trocars
Figure 3: Dissection
Operative time (min) Mean±SD Unilateral Bilateral Blood loss (ml) Mean±SD Days of oral pain pills Mean±SD Hospital stay (hours) Mean±SD Recovery (weeks) Mean±SD Conversion Recurrence Follow-up (months) Mean±SD No. complications (%) Vascular injury Hematoma/seroma Cosmetic result (1-3) Mean±SD Satisfied Partially satisfied Unsatisfied
EESS
Conventional TEP P Value
53.9±11.6 66.79±9.73
39±9.07 53±7.89
0.049 0.014
51.54±13.9
56.25±9.35
0.335
4.65±1.7
5.38±2.6
0.271
18.23±4.94
21.25±8.29
0.123
1.73±0.83 0 0
1.96±0.91 0 0
0.147
15.5±3.38 3/11.5 1 2
25.5±4.38 3/12.5 0 3
