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Year : 2016  |  Volume : 35  |  Issue : 2  |  Page : 132-139

Open preperitoneal mesh repair versus laparoscopic transabdominal preperitoneal repair of groin hernia under spinal anesthesia: results of a prospective randomized multicenter trial

1 General Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Anesthesia Department, Jahraa Hospital, Ministry of Health, Kuwait City, Kuwait; General Surgery Department, Al-Amiri Hospital, Kuwait; General Surgery Department, Al-Ahli Hospital, Qatar

Date of Submission02-Jan-2016
Date of Acceptance01-Feb-2016
Date of Web Publication20-May-2016

Correspondence Address:
Abd-Elrahman Sarhan
MSc, MD, PhD, General Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-1121.182788

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It is difficult to decide on which is the best surgical procedure for groin hernia repair. Several studies have compared laparoscopic groin herniorrhaphy with open Lichtenstein repair. The Lichtenstein procedure is premuscular but laparoscopic repair is preperitoneal. This prospective study compared open preperitoneal modified Kugel procedure with transabdominal preperitoneal (TAPP) laparoscopic repair under spinal anesthesia.
Patients and methods
A total of 200 patients scheduled for unilateral inguinal hernia repair were randomly divided into two groups to undergo either laparoscopic TAPP (group A) or open modified Kugel procedure (group B) under spinal anesthesia in our hospitals (three hospitals) between September 2010 and September 2012. Recurrence was the outcome measure in our comparison, and short-term and long-term complications were also assessed.
There was no significant difference between the two groups in terms of their demographic data. Operative time was significantly shorter in the TAPP group than in the open group (37.8 ΁ 18.4 vs. 64.1 ΁ 20.1 min; P < 0.001). There was significant difference between the two groups in terms of postoperative pain, hospital stay, and recovery with return to work (P < 0.001), but no significant difference in terms of intraoperative complications (P = 0.54), short-term postoperative complications (P = 0.72), wound infection (P = 1.0), and urine retention (P = 0.62). During the follow-up period of 32 months (range = 22-50 months), there were no cases of mortality and no significant difference in terms of recurrence (P = 1.0). Chronic pain and dysesthesia were significantly higher in the open group (P = 0.03 and 0.02, respectively).
Both open and laparoscopic preperitoneal groin hernia repair under spinal anesthesia are effective and safe with low recurrence rates. The laparoscopic approach is better in terms of operative time, return to normal activity, and chronic pain.

Keywords: Groin hernia, modified Kugel, preperitoneal repair, transabdominal preperitoneal

How to cite this article:
Sarhan AE, Sherif T, El-Kenany Y. Open preperitoneal mesh repair versus laparoscopic transabdominal preperitoneal repair of groin hernia under spinal anesthesia: results of a prospective randomized multicenter trial. Egypt J Surg 2016;35:132-9

How to cite this URL:
Sarhan AE, Sherif T, El-Kenany Y. Open preperitoneal mesh repair versus laparoscopic transabdominal preperitoneal repair of groin hernia under spinal anesthesia: results of a prospective randomized multicenter trial. Egypt J Surg [serial online] 2016 [cited 2020 Aug 9];35:132-9. Available from: http://www.ejs.eg.net/text.asp?2016/35/2/132/182788

  Introduction Top

Groin hernia repair is one of the most common surgical procedures [1]. It remains challenging for the surgeons because of its short-term and long-term complications and the fear of recurrence [2]. Several operative techniques have been described. The traditional techniques are tissue-based repair or tension-free repair using an open approach. In recent times, the laparoscopic repair of inguinal hernia has been described using either a totally extraperitoneal or a transabdominal preperitoneal (TAPP) approach [3],[4]. Several studies have established tension-free mesh repair as the gold standard in open inguinal hernia repair [5]. Other studies have shown laparoscopic repair to be safe and efficient. It offers the patient the advantages of minimally invasive surgery and the associated recurrence rate does not differ from that of the classic open tension-free mesh technique. It can be used as a first-line option even for repair of unilateral primary inguinal hernias [6],[7],[8]. Many randomized, controlled trials have been conducted to compare open and laparoscopic procedures. Lichtenstein herniorrhaphy, the open procedure used in most trials, applies a mesh on the premuscular layer and not in the preperitoneal space, unlike the totally extraperitoneal or TAPP laparoscopic technique. This difference in mesh location caused some discrepancies in the comparison between the two approaches, as a result of which the results may not give an exact distinction between the two [9],[10],[11].

Kugel developed a preperitoneal tension-free technique combining the utility of the open operation technique with the advantages of minimal access procedures (smaller incision, preperitoneal mesh placement, avoidance of neuropathic pain) [12],[13]. Transinguinal preperitoneal (TIPP) repair using a modified Kugel (MK) patch is a classic open anterior preperitoneal technique for tension-free herniorrhaphy, performed through the preperitoneal space by means of the internal ring for indirect hernias or Hesselbach's triangle for direct and femoral hernias [1],[14].

Traditionally, general anesthesia is required to perform laparoscopic hernia repair and laparoscopic surgery in general. However, studies have evaluated the efficacy of spinal anesthesia for hernia repair laparoscopically [6],[15].

The layer where the mesh is placed in the preperitoneal space and the regions covered by the mesh in the MK procedure are completely identical to those in the TAPP laparoscopic techniques. The only difference is their approach, open versus laparoscopic. Therefore, we undertook this prospective randomized multicenter study to compare the outcomes of the open MK and laparoscopic TAPP procedures performed under spinal anesthesia taking into consideration immediate postoperative pain during the first 24 h, short-term complications such as urinary retention, seroma, hematoma, and infection, and long-term complications such as recurrence and chronic pain.

  Patients and methods Top


Between September 2010 and September 2012, we conducted this regional prospective randomized study in three hospitals, after obtaining approval from the local ethics committee and informed consent before the operation from the patients. Adult patients admitted for inguinal hernia repair were included in the study. The inclusion criteria were (a) having a unilateral hernia and (b) being of American Society of Anesthesiologists (ASA) grade I, II or III. Exclusion criteria were (a) having bilateral or recurrent hernia or (b) irreducible or strangulated hernia, (c) being of ASA grade IV or V, (d) receiving anticoagulants as treatment, and (e) having a past history of lower abdominal operation. In all, 200 patients were randomly divided into two equal groups: group A underwent laparoscopic TAPP polypropylene mesh repair and group B underwent open MK preperitoneal mesh repair. A computer-generated randomized sequence allocated patients into either group. A single dose of first-generation cephalosporin was given at the time of anesthesia induction. All patients underwent hernia repair by surgeons who performed at least 20 open or laparoscopic repairs [16].

Anesthetic techniques

We used spinal anesthesia in both groups to eliminate the effect of type of anesthesia on the outcome of surgery. Patients were placed in the right lateral decubitus position and a 25-G spinal needle was introduced under complete aseptic technique into the subarachnoid space at the L2-L3 intervertebral space; thereafter, 3 ml of hyperbaric bupivacaine 0.5%, 0.25 mg of morphine, and 20 μg of fentanyl were injected intrathecally. Patients were monitored well and any intraoperative incidents related to the anesthesia or pneumopertioneum, such as changes in cardiopulmonary functions and hemodynamic status, shoulder pain, and nausea, were recorded and patients were informed to ask for conversion of anesthesia at any stage of the procedure.

Laparoscopic procedure (transabdominal preperitoneal)

The procedure was performed as previously described [17]. All patients were placed in the supine position in Trendelenburg position (10-20°) to move the bowel away from the operative field, with both arms tucked against their sides. A Veress needle through supraumbilical incision is used to create pneumoperitoneum up to 15 mmHg. A 10-mm port was inserted through the supraumbilical incision and the abdominal cavity was examined. Two 5-mm ports were placed as working ports, one on each side at the level of the umbilicus in the midclavicular line.

The hernia was inspected and its type confirmed and any contralateral asymptomatic hernia sac was identified and dealt with. The contents of the inguinal hernia were reduced whenever present [Figure 1].
Figure 1: Indirect inguinal hernia.

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Peritoneal flap was prepared from the level of the anterior superior iliac spine to the lateral umbilical ligament 2 cm above the internal ring [Figure 2]. Direct and small indirect hernia sacs were fully reduced. Larger indirect sacs were partially dissected and resected and its distal part left in situ. The anatomy now is clear (Cooper's ligament, inferior epigastric vessels and the spermatic cord). The iliac vessels are not dissected but their positions are clearly identified. The dissection is carried to the symphysis medially.
Figure 2: Incision of the peritoneum and creation of preperitoneal space.

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A polypropylene mesh of 15×12 cm was used for the repair. The mesh was introduced into the operating field through the 10-mm umbilical port after removing the telescope to cover the entire myopectineal orifice and was fixed to Cooper's ligament and the anterior abdominal wall with tacks [Figure 3]. The medial border of the mesh is adjacent to the symphysis pubis and the upper part is placed at least 2-3 cm over the hernia defect and internal ring. The peritoneum is then reapproximated with the tacks [Figure 4]. The carbon dioxide gas was evacuated to empty the abdominal cavity and scrotum. All trocars were removed; the 10-mm trocar site was closed with vicryl sutures. Skin incisions were closed with simple sutures.
Figure 3: Mesh fixation by tucker.

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Figure 4: Peritoneum reapproximation.

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Open procedure (modified Kugel)

The open MK procedure was performed as described [14]. We started with a transverse skin crease incision 5-6 cm long, deepened to the external oblique aponeurosis, and delivery of the cord; indirect sacs were dissected from the cord [Figure 5] up to the extraperitoneal fat and inverted into the deep ring after elevation of the inferior epigastric vessels anteromedial to create the preperitoneal space [Figure 6]. Gauze was inserted through the internal ring to keep the peritoneal sac inverted. The direct sac was isolated and the transversalis fascia around its neck was circumcised and the preperitoneal space reached directly. Dissection of the preperitoneal space can be done with Gauze swabs [Figure 7]. We continued dissection to the pubic tubercle medially, the iliac vessel laterally, and Cooper's ligament caudally.
Figure 5: Indirect sac dissected.

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Figure 6: Sac inverted into deep ring.

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Figure 7: Dissection of preperitoneal space using gauze.

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We used an MK hernia patch (monofilament knitted polypropylene mesh 13.0 × 9.5 or 12.0 × 8.0 cm in size, which comprised a double layer containing a pocket, strap, and memory recoil ring), which was inserted into the preperitoneal space [Figure 8] covering the entire groin area including indirect, direct, and femoral orifices. Once the patch was in place, its position was checked by inserting the index finger into the preperitoneal space between the inguinal ligament and mesh with boundaries of mesh covering Cooper's ligament caudally, iliac vessels laterally, and the rectus abdominis medially. Straps of patch were fixed to the transversalis fascia with vicryl suture and the mesh was fixed in place with abdominal pressure. After closure of the external oblique and Scarpa's fascia with a running 3-0 vicryl suture, the skin incision was closed with a running subcuticular stitch.
Figure 8: Mesh inserted into preperitoneal space.

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Data collection

Type of hernia, duration of operation, visual analogue scale (VAS) at 24 h, length of hospital stay, intraoperative complications, short-term and long-term postoperative complications, and incidence of recurrence were recorded.

Patients were examined in the outpatient clinic 2 weeks, 1 month, 3 months, and 1 year postoperatively and then annually for complications or recurrence.

Statistical analysis

Continuous data were presented as mean±SD and compared using the Student t-test (two-tailed). Frequencies were compared using the Pearson χ2 -test and Fisher's exact test. Data analysis was performed using SPSS for windows version 13 (SPSS, Inc, Chicago, IL).

A P value less than 0.05 was considered statistically significant.

  Results Top

Between September 2010 and September 2012, 200 patients were included in this study and were divided into two groups: group A (100 patients) underwent laparoscopic TAPP repair and group B (100 patients) underwent the open MK procedure.

[Table 1] shows the demographic data of the patients according to the treatment group. There were no significant differences between the two groups. Most of the patients were male; hernia was mostly on the right side and contralateral; clinically occult inguinal hernia was detected in 10 patients (10%) in the TAPP group and was managed at the same time; according to Nyhus classification indirect and direct types of hernia were the most common.

Intraoperative data and all postoperative complications during the follow-up period of 32 months (range = 22-50 months) were recorded. Follow-up included a physical examination at the outpatient clinic 2 weeks, 3 months, and 1 year after surgery and then annually thereafter to detect the long-term postoperative complications.
Table 1: Demographic data of the patients in the two groups

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[Table 2] shows the operative data and short-term postoperative complications.
Table 2: Operative data and short-term post operative complications

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The operative time in the laparoscopic group was shorter than that in the open group (37.8 ± 18.4 for TAPP vs. 64.1 ± 20.1 for MK) and the difference was significant (P < 0.001).

Length of hospital stay was longer in the open group and the difference from the laparoscopic group was significant (1.4 ± 0.57 for TAPP vs. 1.7 ± 0.53 for MK; P < 0.001). In addition, the laparoscopic group had lower VAS scores and patients returned to work earlier than did the patients of the open group and the difference was significant (P < 0.001).

The overall complication rate of the laparoscopic group was lower than that of the open group (14 vs.18%) (P = 0.028) as both groups showed comparable results regarding intraoperative and short-term postoperative complication rates, as shown in [Table 2], and the open group had a higher long-term complication rate, as shown in [Table 3].
Table 3: Long-term postoperative complications

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The most serious complication we faced during our study was inferior epigastric vessel injury, with two cases in the laparoscopic group and three cases in the open group, which was controlled intraoperatively by ligation of the artery using clips or ligature. Urinary bladder injury occurred in one patient in the laparoscopic group, which was a small tear discovered intraoperatively and repaired with sutures and Foley's catheter insertion for 1 week with antibiotic cover, and the patient was discharged without further treatment.

Early postoperative complications were minimal in both groups; seroma was the most common complication and occurred in patients with a large sac that was not dissected completely; all patients with seroma were treated conservatively with scrotal support. There was no significant difference between the two groups in terms of postoperative seroma.

No significant difference in the incidence of postoperative wound infection was observed between the two groups as we had two patients in each group with minimal postoperative wound infection, which was treated conservatively with dressing under antibiotic cover.

Intraoperative and short-term complications related to spinal anesthesia (the type of anesthesia we used in both groups) were minimal; only shoulder pain and/or discomfort occurred in 18 patients (18%) under the laparoscopic approach, which was managed with medications alone. Bradycardia, seen in 15 patients (15%), was the main drawback in the open group, which reversed easily with atropine.

Urinary retention is one of the most common short-term complications we faced in the immediate postoperative period (35 vs. 31% in the laparoscopic group and open group, respectively; P = 0.62) and manifested as lower abdominal pain. It was managed by hot fomentation to the lower abdomen and/or overnight urinary bladder catheterization.

Long-term postoperative complications are shown in [Table 3]. The overall recurrence rate in this study was 2% (one case in each group, 1%); all recurrences occurred within the first year postoperatively. One case of port site hernia was detected in the laparoscopic group and there was no mortality related to surgery in our study. There was significant difference between the two groups in term of postoperative dysesthesia and chronic pain (5% in the laparoscopic group vs. 15% in the open group for dysesthesia; and 1% in the laparoscopic group vs. 7% in the open group for chronic pain).

  Discussion Top

Until a few decades ago, the standard method for inguinal hernia repair was suturing fascial structures around the hernia defect, until Lichtenstein et al. [18] introduced tension-free repair, which gained widespread recognition worldwide and surgeons mastered the technique rapidly.

Successful hernia treatment should offer high patient satisfaction, low cost, low recurrence rate, and rapid return to work [19]. Laparoscopic and open hernia repairs fulfill these criteria [20]. However, the question about the most appropriate technique still confuses the community of surgeons.

There are advantages and disadvantages to laparoscopic repair. Clinically silent contralateral hernia and other intra-abdominal pathologies are easier to detect with the TAPP approach [8],[21]. The laparoscopic TAPP procedure carries some disadvantages such as possible organ injury at the time of trocar entry, port site hernia, and adhesions [22].

Despite excellent long-term outcome after TAPP repair, the use of laparoscopy in hernia repair is still limited [23].

Several studies have compared the laparoscopic and open techniques for inguinal hernia repair; some studies employed open techniques [24], and others adopted the laparoscopic approach [1],[25].

Open preperitoneal tension-free repair started with Wantz, but because of its complicated steps and associated major injuries it is less frequently used [26],[27]. MK is another open preperitoneal procedure, different from the original Kugel technique in its approach, in that MK adopts the anterior approach, which is familiar to surgeons [28].

Most of these studies compared laparoscopic and Lichtenstein tension-free techniques with different mesh locations, mesh types, and different types of anesthesia.

In our prospective study, we used two different techniques; both were tension free (laparoscopic TAPP and open transinguinal preperitoneal), with different approaches but with similar mesh location. The mesh was placed in the preperitoneal space between the peritoneum and the transversalis fascia, and secured over the myopectineal orifice using intra-abdominal pressure, covering the Hasselbach triangle, the internal inguinal ring, and treating the three most common types of groin hernia: indirect, direct, and femoral hernia.

What facilitated this study is the fact that the MK procedure is frequently used in our centers, which made it easy to compare between the laparoscopic and open approaches for preperitoneal inguinal hernia repair.

Although the most important outcome after repair of inguinal hernia is prevention of recurrence, other factors such as safety of the patients, quality of life, and cost efficiency are very important.

In our study, we found that both open and laparoscopic approaches are effective and safe for preperitoneal repair of inguinal hernia, with low complication and recurrence rates.

Recurrence was the main outcome measure in our study. Our results showed a low and similar recurrence rate in both approaches (1% in both), comparable to the results of Li et al. [1], and is within the range of reported recurrence rates after laparoscopic inguinal hernia repair (0-4%) [8],[29] or open MK procedure (0-2%) [14].

Adequate dissection of the preperitoneal space with a large enough mesh with flattening and overlapping to cover the whole myopectineal orifice minimizes and avoids recurrence.

The duration of inguinal hernia repair with the TAPP technique has been reported to be between 30 and 65 min [22],[30], and that with the MK procedure has been reported to be (30 to 55) min [14, 31, 32]. The operation time in our study was significantly shorter with the laparoscopic approach (37 ± 18.4 vs. 64.1 ± 20.1 with the open approach; P < 0.001). This could be attributed to the new MK technique being practiced in our centers, compared with TAPP.

One of the advantages of the laparoscopic approach over the open approach is less pain postoperatively [1]. In our work, VAS was significantly lower in the TAPP group than in the MK group, which could be attributed to the fact that groin dissection using the open anterior approach causes more trauma and possible injury to the peripheral nerves.

A seroma or hematoma developed in a total of 11% of cases, five patients in the laparoscopic group and six patients in the open group. All cases of seroma or hematoma improved through conservative methods. Our rates were similar to those reported in the literature [8],[30].

There was one case of port site hernia in the TAPP group during the follow-up period of 32 months (range = 22-50 months), similar to the results of Oguz et al. [8] and those of Helgstrand et al. [33], which reported an incidence of port site hernia of between 0 and 3.9%.

There were no major complications in our study. There were only a few cases of inferior epigastric or bladder injury without significant difference between the two groups, which indicates the safety of both techniques.

According to our findings, other significant advantages of the TAPP procedure over MK repair were short hospital stay and earlier recovery. Meta-analysis of multiple randomized controlled trials of TAPP repair showed a return to normal activities 3 days earlier than open repair [34].

The method of anesthesia, in addition to the surgical technique, affects patient satisfaction. The recent use of regional anesthesia in laparoscopic hernia repair has proven its safety and efficacy [4],[15],[35]. In this study we tried to evaluate the effect of spinal anesthesia on the outcome of surgery, especially laparoscopic surgery; its use seems interesting as two minimally invasive procedures are used together in the same patient. In our series, regional anesthesia was efficient and there was no need for conversion to general anesthesia, nor were there anesthesia-related complications such as headache, blurring, or dizziness. The only drawback of spinal anesthesia is retention of urine, as we faced 35 cases in the TAPP group and 31 cases in the open group. Our results were comparable to the results of other studies using spinal anesthesia in laparoscopic hernia repair [4],[6],[15],[36], but were better than the results of TAPP repair under general anesthesia [8],[37]. The question is whether urinary retention is due to anesthesia approach, surgical procedure, or both. We thought it was a combination of both: effect of spinal anesthesia on bladder tone and dissection in the area of the bladder. Despite this most of our patients were satisfied with their operations.

Lastly, regarding chronic pain and dysesthesia, we found significant difference between the two groups (1 and 5% in the TAPP group vs. 7 and 15% in the open group) for chronic pain and dysesthesia, respectively, similar to other studies on the TAPP [4],[6],[8] and MK procedures [1],[4]. In the TAPP procedure, chronic pain is considered to be a result of the compression of the nerves that pass the region and are compressed by the mesh or tacker. We tried to reduce the number of staples applied and avoid nerve injuries, which helps in reduction of postoperative pain. One of the causes of chronic pain in the MK procedure is the presence of the stiff outer ring. At 1-year follow-up, only one patient still had chronic pain.

The advantage of our study is that it is a prospective randomized trial, comparing inguinal hernia repair under the same type of anesthesia (spinal), the same mesh position (preperitoneal), and the same type of mesh (polypropylene).

The limitation of our study is the small number of patients and the relatively short period of follow-up.

  Conclusion Top

A lot of surgical techniques are available for hernia repair, and the choice of best type of surgery depends on several factors. According to our prospective study, both open MK and laparoscopic TAPP preperitoneal repair techniques for inguinal hernia are safe and effective with low recurrence rates.

Laparoscopic approach has better outcome in terms of chronic pain, short operative time, and short duration of hospital stay.

Spinal anesthesia is a safe and effective procedure with no effect on the outcome of repair quality.

Further studies with large sample size and longer follow-up duration are needed to prove our results. Further prospective studies comparing laparoscopic hernia repair under spinal anesthesia and that under general anesthesia are also needed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2], [Table 3]


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