World J Surg DOI 10.1007/s00268-014-2495-1
Trans-Rectus Sheath Extra-Peritoneal Procedure (TREPP) for Inguinal Hernia: The First 1,000 Patients Danny Rosin
Socie´te´ Internationale de Chirurgie 2014
‘‘There must be 50 ways to leave your lover’’ [1] but surely many more to fix a hernia. So what do you need in order to develop yet another variant? Start with a fresh look at the anatomy and ways to get there, apply several attractive concepts like ‘‘preperitoneal mesh’’ or ‘‘minimally invasive’’ (whatever that means in a relatively small operation anyway), add to that some enthusiasm in order to quickly spread the gospel, get a large group of patients, better have some industry support with a dedicated mesh (at least initially), and invent a nice and catchy acronym (which better not sound negative, like a trap). Cynicism aside, what are we looking for, nowadays, when we choose what method to use to fix an inguinal hernia? •
•
Low recurrence rate This is a no-brainer, and with the widespread use of mesh, it is rarely an issue today. Most of the variants of primary, layered tissue repair were sent into oblivion or into surgical history. How many residents have heard about McVay, let alone know how to do it? Low cost Although the mesh industry is flourishing, and new (and expensive) meshes appear in the market faster than we can say ‘‘polypropylene,’’ the price of a small piece of polypropylene mesh is reasonable in most circumstances. ‘‘Special mesh’’ products such as selfadhering mesh, light-weight, ‘‘anatomical,’’ or ‘‘anti adhesion’’ all have their added cost, which may be prohibitive for some patients.
D. Rosin (&) General Surgery and Transplantation, Sheba Medical Center, Ramat Gan, Israel e-mail: [email protected]
•
•
Easy recovery Minimal tissue trauma, resulting in less pain and quicker healing, is translated to earlier return to full activity. While it is not that easy to improve on what is already considered a small and easy operation (e.g., ‘‘classic’’ open hernia repair), we do have data to support the claims that ‘‘it can be better than that.’’ Postoperative pain, both early and chronic, is an important target that novel techniques claim to improve. Simplicity This is probably the most difficult to achieve. Hernia surgery is never really simple, and mastery of anatomy, technique, materials, and various repair options is mandatory in order to be a good hernia surgeon. The Lichtenstein technique is simple, easy to understand, easy to do, and easy to teach and this is why it has become so widespread.
In this issue of the World Journal of Surgery, Lange et al. [2] present their impressive results with their new TREPP technique: 1,000 patients were operated on using a preperitoneal mesh inserted through the rectus abdominis muscle route. With a 1 % hernia recurrence rate and a 90 % pain-free recovery rate, this technique is certainly ‘‘in the game.’’ This technique, based on the use of a selfexpanding mesh, joins several other open preperitoneal variants; however, entering more medially, behind the rectus muscle, is claimed to be an advantage, avoiding the more lateral nerves. The retrospective nature of this study and the fact that in bilateral cases the incidence of chronic pain was higher somewhat weaken this claim, however. The TREPP technique certainly satisfies the first three requirements mentioned above. The fourth parameter, however, is much less obvious. The operative approach (if we forget about the access for a minute) is very similar to the laparoscopic total extra-peritoneal (TEP) approach,
123
World J Surg
which starts behind the rectus muscles and progresses from medial to lateral. Also, no one claims that TEP is simple or has a short learning curve. In addition, after creating the necessary space, TEP is done under complete visual control, while in TREPP much of the dissection is blunt and with what seems like a less than optimal view. It reminds me of the ‘‘minicholecystectomy’’ operation in the early years of laparoscopic cholecystectomy, in which what is done under full visual control the surgeon tried to achieve through a small incision. This is destined to be praised by some enthusiasts but rejected by the majority of surgeons, who find it cumbersome and unattractive. Of course I may
123
be wrong: ‘‘I just hope my meaning won’t be lost or misconstrued’’ [1].
References 1. Simon P (1975) ‘‘Fifty ways to leave your lover,’’ Still Crazy After All These Years, Columbia Records (then Warner Bros.) 2. Lange JFM, Lange MM, Voropai DA et al (2014) Trans Rectus sheath Extra-Peritoneal Procedure (TREPP) for inguinal hernia: the first 1,000 patients. World J Surg. doi: 10.1007/s00268-0142475-5
Trans-Rectus Sheath Extra-Peritoneal Procedure (TREPP) for Inguinal Hernia: The First 1,000 Patients Danny Rosin
Socie´te´ Internationale de Chirurgie 2014
‘‘There must be 50 ways to leave your lover’’ [1] but surely many more to fix a hernia. So what do you need in order to develop yet another variant? Start with a fresh look at the anatomy and ways to get there, apply several attractive concepts like ‘‘preperitoneal mesh’’ or ‘‘minimally invasive’’ (whatever that means in a relatively small operation anyway), add to that some enthusiasm in order to quickly spread the gospel, get a large group of patients, better have some industry support with a dedicated mesh (at least initially), and invent a nice and catchy acronym (which better not sound negative, like a trap). Cynicism aside, what are we looking for, nowadays, when we choose what method to use to fix an inguinal hernia? •
•
Low recurrence rate This is a no-brainer, and with the widespread use of mesh, it is rarely an issue today. Most of the variants of primary, layered tissue repair were sent into oblivion or into surgical history. How many residents have heard about McVay, let alone know how to do it? Low cost Although the mesh industry is flourishing, and new (and expensive) meshes appear in the market faster than we can say ‘‘polypropylene,’’ the price of a small piece of polypropylene mesh is reasonable in most circumstances. ‘‘Special mesh’’ products such as selfadhering mesh, light-weight, ‘‘anatomical,’’ or ‘‘anti adhesion’’ all have their added cost, which may be prohibitive for some patients.
D. Rosin (&) General Surgery and Transplantation, Sheba Medical Center, Ramat Gan, Israel e-mail: [email protected]
•
•
Easy recovery Minimal tissue trauma, resulting in less pain and quicker healing, is translated to earlier return to full activity. While it is not that easy to improve on what is already considered a small and easy operation (e.g., ‘‘classic’’ open hernia repair), we do have data to support the claims that ‘‘it can be better than that.’’ Postoperative pain, both early and chronic, is an important target that novel techniques claim to improve. Simplicity This is probably the most difficult to achieve. Hernia surgery is never really simple, and mastery of anatomy, technique, materials, and various repair options is mandatory in order to be a good hernia surgeon. The Lichtenstein technique is simple, easy to understand, easy to do, and easy to teach and this is why it has become so widespread.
In this issue of the World Journal of Surgery, Lange et al. [2] present their impressive results with their new TREPP technique: 1,000 patients were operated on using a preperitoneal mesh inserted through the rectus abdominis muscle route. With a 1 % hernia recurrence rate and a 90 % pain-free recovery rate, this technique is certainly ‘‘in the game.’’ This technique, based on the use of a selfexpanding mesh, joins several other open preperitoneal variants; however, entering more medially, behind the rectus muscle, is claimed to be an advantage, avoiding the more lateral nerves. The retrospective nature of this study and the fact that in bilateral cases the incidence of chronic pain was higher somewhat weaken this claim, however. The TREPP technique certainly satisfies the first three requirements mentioned above. The fourth parameter, however, is much less obvious. The operative approach (if we forget about the access for a minute) is very similar to the laparoscopic total extra-peritoneal (TEP) approach,
123
World J Surg
which starts behind the rectus muscles and progresses from medial to lateral. Also, no one claims that TEP is simple or has a short learning curve. In addition, after creating the necessary space, TEP is done under complete visual control, while in TREPP much of the dissection is blunt and with what seems like a less than optimal view. It reminds me of the ‘‘minicholecystectomy’’ operation in the early years of laparoscopic cholecystectomy, in which what is done under full visual control the surgeon tried to achieve through a small incision. This is destined to be praised by some enthusiasts but rejected by the majority of surgeons, who find it cumbersome and unattractive. Of course I may
123
be wrong: ‘‘I just hope my meaning won’t be lost or misconstrued’’ [1].
References 1. Simon P (1975) ‘‘Fifty ways to leave your lover,’’ Still Crazy After All These Years, Columbia Records (then Warner Bros.) 2. Lange JFM, Lange MM, Voropai DA et al (2014) Trans Rectus sheath Extra-Peritoneal Procedure (TREPP) for inguinal hernia: the first 1,000 patients. World J Surg. doi: 10.1007/s00268-0142475-5
