The role of the laparoendoscopic single site totally extraperitoneal approach to inguinal hernia repairs: a review and meta-analysis of the literature

Single incision laparoscopic totally preperitoneal hernioplasty (SIL-TPP): Lessons learned from 102 procedures and initial experience

BACKGROUND

The abdominal wall in groin area is conventionally considered that it was comprised by 9 layers. Single incision laparoscopy totally extraperitoneal hernioplasty (SIL-TEP) reported before were operated through the front of the posterior rectus sheath.

METHOD

102 SIL-TPP were conducted from October 2018 to October 2020 at The Affiliated Hospital of Medical School of Ningbo University using a self-made single-port device and standard laparoscopic instruments. Clinical data, demographic and intraoperative findings, and short-term postoperative outcomes were analyzed.

RESULTS

Of the 102 hernias treated, 46 were right inguinal hernias, 33 were left inguinal hernias and 23 were double-side inguinal hernias. All patients received the SIL-TPP and no conversion happened. The mean left-side and right-side hernia operative time was almost same. The left-side and right-side operative time were 75.48 ± 26.95 and 76.24 ± 26.09 minutes, respectively. The mean operative time was 75.92 ± 26.45 (range, 29-170 minutes) in unilateral inguinal hernia. Mean operative time was 104.17 ± 28.58 minutes (range, 67-180 minutes) in double-side inguinal hernia. The intraoperative complications rate was 21.57 (22/102) and all the complications were Peritoneum or sac tearing. Postoperative complications occurred in 3 cases (1 case wound seroma, 1 case urinary retension and 1 case upper respiratory infection) and were successfully treated conservatively. The mean hospital stay was 2.8646 ± 1.38 days. The 24 hours Visual analogue scale score was 2.28 ± 0.77. During follow-up to June 2022, no recurrence case occurred.

CONCLUSION

SIL-TPP is safe and feasible. SIL-TPP has its unique skills and advantages to treat inguinal hernia. Large-scale randomized controlled trials comparing SIL-TPP inguinal hernia repair with conventional single port and conventional three port laparoscopic totally extraperitoneal hernioplasty with short-term outcome and long-term recurrence rate are needed to confirm these results.

Outcomes of 207 totally extraperitoneal hernia repairs using self-fixation mesh

Inguinal hernia (IH) repair is one of the most common procedures in general surgery around the world. Minimizing postoperative acute and chronic pain without increasing recurrence has been a critical point, giving place to different strategies like self-fixation mesh. The current study aimed to describe a group of patients who underwent IH repair by Totally Extraperitoneal (TEP) technique with self-gripping mesh at a fourth level hospital between 2012 and 2019. Retrospective review of a prospectively collected database including patients who underwent laparoscopic TEP approach with self-fixation mesh for IH repair. Follow up data was obtained at 12, 24, 36, 48, and 60 months post surgical intervention. 207 hernia repairs were performed in 142 patients, with a total of 66 patients with bilateral IH. 10.6% required hospitalization due to either concomitant procedure performed or cardiovascular comorbidities, with a mean hospital stay of 1.6 days. Median and late follow up was up to 5 years. 88.9% of patients complete a year, 86% two years, and 36.7% with a 5 year follow-up. IH repair using the TEP technique and self-fixation mesh showed to be an excellent approach, demonstrating satisfactory results in follow up and complications.

Laparoscopic Single-Site Inguinal Hernia Repair Using a Self-Fixating Mesh

Background and Objectives:

Every year ∼20 million inguinal hernia repairs are completed worldwide. Increased patient access to medical information and education has elicited interest in minimally invasive surgical techniques that obtain improved surgical outcomes and cosmesis. Because of these factors, there is a growing interest in single-incision surgery. Laparoscopic totally extraperitoneal (TEP) single-incision hernia repair technique has been reported with different meshes used in a tack fixation system. Recently, self-fixating mesh technology has offered the possibility of avoiding tack fixation and potentially avoiding chronic postoperative pain. Self-fixating mesh technology employs monofilament polylactic acid (PLA) creating a microgrip system that provides self-adherence of the mesh to adjacent tissue. This tack-free fixation system provides coverage over the entire myopectineal orifice and surrounding areas where traditional tacks cannot be placed. Self-fixating mesh has also been safely applied in laparoscopic TEP procedures, but this mesh has not been described in single site TEP surgery; possibly because of the potential difficulty with mesh deployment. We sought to determine the technical feasibility of a single-site laparoscopic TEP repair of inguinal hernias and to discuss our techniques and patient short-term outcomes.

Methods:

Review of a prospectively maintained database of patients who received single-site laparoscopic TEP herniorrhaphy from August 2012 through August 2015. Patient characteristics and demographics and perioperative and postoperative data were analyzed.

Results:

Thirty-four patients (aged 55.2 ±14.2; 17.6% women) with a mean body mass index of 26.2 ± 3.9 were analyzed. Mean operative time was 99.5 ± 30.5 minutes, 41.2% were left-side repairs, and 50% were bilateral. Estimated blood loss was 18.4 ± 14.1 mL. Recurrent hernias accounted for 14.7% of cases; 32.4% of cases were combination surgeries, most commonly a concurrent umbilical hernia repair. The most common short-term postoperative complication was urinary retention (4 patients). The median length of follow-up was 25 days (IQR 18.75–61.75). Complications occurring at >30 days included hydrocele (2 patients) and stitch abscess (1 patient). Eight (23.5%) patients had complications (surgical or during follow-up). No recurrences or deaths were reported.

Conclusions:

With comparable operative times, perioperative outcomes, and safety profile, SS-TEP appears to be a safe and effective surgical approach for the management of inguinal hernias in the short term. Furthermore, SS-TEP with a self-fixating mesh is a feasible approach.

Single incision multiport versus conventional laparoscopic inguinal hernia repair: A matched comparison

Background:

The popularity of single-incision procedures is on the rise as wound cosmesis is increasingly being seen as an important body image-related outcome. In this study, we assess the potential benefits of single-incision multiport laparoscopic totally extra-peritoneal (S-TEP) without using specialised ports or instruments and compare the same with the conventional laparoscopic TEP (C-TEP) surgery in terms of operative time, post-operative pain, complications, cost and cosmesis.

Materials and Methods:

This is a prospective case-matched study of the patients undergoing S-TEP versus C-TEP from June 2014 to December 2015.

Results:

Each group had 36 patients. The two groups were comparable in the clinical characteristics. The mean duration of surgery for a unilateral hernia in C-TEP and S-TEP was 45.13 ± 10.58 min and 72.63 ± 15.23 min, respectively. The mean visual analogue scale (VAS) score for pain was significantly higher in S-TEP group at post-operative day (POD) 0 and 1. However, at POD 7, there was no significant difference between the groups. At 1^st and 6-week post-surgery, the cosmetic results were significantly better in S-TEP group as compared to C-TEP, however, at 6 months, the scar was highly acceptable in both treatment groups.

Conclusion:

S-TEP, using conventional laparoscopic instruments, is safe and feasible even in resource challenged setting. However, there is a need to review the indications and advantages of single-incision laparoscopic surgery, as no difference in cosmetic outcome by VAS score in S-TEP versus conventional laparoscopic arm seen by the end of 1 month.

Laparoendoscopic single-site surgery in inguinal hernia repair

Laparoendoscopic single-site surgery (LESS) for laparoscopic inguinal hernia repair (IHR) offers the potential for excellent cosmetic outcomes and maximization of the inherent advantages of minimally invasive surgery. LESS IHR is associated with a steep learning curve, which is attributable to both the IHR technique itself and the single-site technique. The technical obstacles in the single-site technique may be mitigated by employing certain maneuvers and strategies that minimize clashing between instruments and improve freedom of movement. The current literature consistently points out the inherent challenges in LESS IHR, with its longer operative time compared to that of conventional laparoscopic IHR. LESS IHR performed by capable operators has comparable complication rates, duration of hospital stay, and incidence of recurrence as conventional laparoscopic IHR. LESS IHR is both feasible and safe. Given its excellent cosmetic outcome, it is likely to be sought by younger patients who are concerned with scar formation. The use of robotics may bypass the technical challenges in LESS, but cost considerations in their usage will likely persist.

Single-Incision Laparoscopic Inguinal Hernioplasty Versus Conventional Laparoscopic Inguinal Hernioplasty

PURPOSE

Additional studies comparing single-incision laparoscopic inguinal hernioplasty (SILH) and conventional laparoscopic inguinal hernioplasty (CLH) have been published, and this study updates the meta-analysis of this subject.

METHODS

Two reviewers independently searched the PubMed, Embase, Google Scholar, and Cochrane Library electronic databases to locate original articles that compared SILH and CLH for inguinal hernia that were published until October 2015. Operative time, conversions, complications, length of hospital stay, recurrence, postoperative pain at 24 hours, and postoperative pain at 7 days were compared using Stata software, version 12.0.

RESULTS

Sixteen studies were selected for this analysis, which included a total of 1672 patients (907 in SILH and 765 in CLH). SILH showed a longer operative time; however, conversions, complications, length of hospital stay, recurrence, postoperative pain at 24 hours, and postoperative pain at 7 days were similar between the 2 groups.

CONCLUSIONS

Our meta-analysis has shown that inguinal hernia repair using SILH is as safe as CLH. However, based on our evidence, we currently believe that SILH is not an efficacious surgical alternative to CLH for inguinal hernias due to the fact that it does not provide significant benefit in postoperative pain and cosmetic outcomes. However, large-scale, well-designed, and multicenter studies will be needed to further confirm the results of this study.

Single-port versus conventional three-port laparoscopic totally extraperitoneal inguinal hernia repair: a randomized controlled trial

BACKGROUND

Single-port laparoscopic surgery (SPLS) has been introduced for totally extraperitoneal (TEP) inguinal hernia repair. Clinically, however, the benefits of single-port TEP (SP TEP) are unclear. This study aimed to compare short-term surgical outcomes between SP TEP and conventional laparoscopic TEP(CL TEP) inguinal hernia repair.

METHODS

Between January 2013 and February 2015, 99 men with primary unilateral inguinal hernia were randomized to the single-port or conventional 3-port TEP procedures. The primary end point was postoperative pain. Secondary end points were complications, postoperative hospital stay, days to return to daily normal activities, cosmesis, and quality of life (QOL).

RESULTS

We randomized 50 patients to SP TEP and 49 to CL TEP repair. The SP TEP group patients had significantly lower pain scores (visual analog scale) 7 days postoperation (p = 0.017). However, there were no significant differences between the two groups in postoperative pain scores 24 h (p = 0.44) and 4 weeks (p = 0.677) after operation and analgesic requirements on the operation day (p = 0.303) and 7 days after the operation (p = 0.204). Operation time, postoperative hospital stay, and complications were comparable between the two groups. The days to return to daily normal activities, QOL, and cosmetic satisfaction were not different between the two groups.

CONCLUSION

The outcomes of SP TEP hernia repair for operation time and morbidities were comparable to CL TEP, and postoperative pain was lower at 7 days than in CL TEP hernia repair. The SP TEP technique can be recommended as an alternative treatment for inguinal hernia repair in experienced hands.

Comparison of surgical effect and postoperative patient experience between laparoendoscopic single-site and conventional laparoscopic varicocelectomy: a systematic review and meta-analysis

The present meta-analysis was conducted to compare the clinical effect and patient experience of laparoendoscopic single-site varicocelectomy (LESSV) and conventional laparoscopic varicocelectomy. The candidate studies were included after literature search of database Cochrane Library, PubMed, EMBASE, and MEDLINE. Related information on essential data and outcome measures was extracted from the eligible studies by two independent authors, and a meta-analysis was conducted using STATA 12.0 software. Subgroup analyses were conducted by study design (RCT and non-RCT). The odds ratio (OR) or standardized mean difference (SMD) and their 95% confidence intervals (95% CIs) were used to estimate the outcome measures. Seven articles were included in our meta-analysis. The results indicated that patient who had undergone LESSV had a shorter duration of back to work (overall: SMD = −1.454, 95% CI: −2.502–−0.405, P = 0.007; non-RCT: SMD = −2.906, 95% CI: −3.796–−2.017, P = 0.000; and RCT: SMD = −0.841, 95% CI: −1.393–−0.289, P = 0.003) and less pain experience at 3 h or 6 h (SMD = −0.447, 95% CI: −0.754–−0.139, P = 0.004), day 1 (SMD = −0.477, 95% CI: −0.905–−0.05, P = 0.029), and day 2 (SMD = −0.612, 95% CI: −1.099–−0.125, P = 0.014) postoperatively based on RCT studies. However, the meta-analyses based on operation time, clinical effect (improvement of semen quality and scrotal pain relief), and complications (hydrocele and recurrence) yielded nonsignificant results. In conclusion, LESSV had a rapid recovery and less pain experience over conventional laparoscopic varicocelectomy. However, there was no statistically significant difference between the two varicocelectomy techniques in terms of the clinical effect and the incidence of hydrocele and varicocele recurrence. More high-quality studies are warranted for a comprehensive conclusion.

Comparison of laparoendoscopic single-site versus conventional multiple-port laparoscopic herniorrhaphy: a systemic review and meta-analysis

PURPOSE

We systemically reviewed published literatures and performed meta-analysis to compare the surgical outcomes between laparoendoscopic single-site over the multiple-port total extraperitoneal approach in hernia repair.

METHODS

We did a systemic search of PubMed and Cochrane review for all randomized controlled trials and comparative trials that compared the efficacy and safety between LESS-TEP and MP-TEP. The evaluated outcomes included perioperative parameters (operative time, conversion rate), hospital stay and complications (seroma, delayed return of bladder function, postoperative pain and recurrence). The Cochrane Collaboration Review Manager software (RevMan, version 5.2.6) was used for statistical analysis.

RESULTS

There were 10 trials met the inclusion criteria and included for meta-analysis. Totally, there were 595 and 514 patients underwent LESS-TEP and MP-TEP, respectively. The LESS-TEP took significantly longer-operative time than the MP-TEP in unilateral hernia repair (weighted mean difference (WMD) 4.11 min, 95% CI 0.76-7.46, p = 0.02) while not in bilateral hernia repair (WMD 3.87 min, 95% of CI -2.59-10.33, z = 1.17, p = 0.24). There were no significant differences in surgical outcomes with regard to postoperative pain scale, conversion rate, hospital stay, recurrence rate and complication rate between two groups. The length of the sub-umbilical wound was the same in both groups. The result of cosmesis was not compared because of the limited data.

CONCLUSION

In experienced hands, LESS-TEP is a feasible alternative to MP-TEP with comparable surgical efficacy and morbidity, but with longer operation time in unilateral hernia repair. Potential advantages of LESS-TEP including better cosmesis, less postoperative pain and less trocar-associated complications were not clearly shown.

99mTc-MDP uptake in SPECT/CT by a bladder hernia simulating inguinal metastasis: A case report

A 72-year-old male with a history of prostate cancer and high prostate specific antigen levels underwent ^99mtechnetium-methylene diphosphonate (^99mTc-MDP) single-photon emission computed tomography/computed tomography (SPECT/CT), to identify bone metastasis. The patient possessed no previous history of serious illnesses or surgical procedures and no family history of malignancies. A whole-body CT scan revealed an intense MDP uptake in the right inguinal region on the anterior view, but not in the posterior view, which was suspected to be a metastatic lesion. However, there was no evidence of bone metastasis on the CT scan. In addition, an increased ^99mTc-MDP uptake was indicated on the SPECT images in the right inguinal region, which appeared to be separate from the main bladder activity. CT images of the pelvis revealed an inferior tongue-like extension of the bladder into the right inguinal region. Fused SPECT/CT axial images indicated the circular accumulation of the ^99mTc-MDP in the medial right groin, with well-defined walls that connected the accumulation to the bladder. The final diagnosis was a bladder hernia (T2N0M0), which may have been responsible for the misdiagnosis of bone metastasis due to the use of radiopharmaceuticals (^99mTc-MDP) that were mainly excreted through urination. Considering the comprehensive situation of the patient, radical prostatectomy was performed. The bladder hernia was subsequently monitored by follow-up examination every 3 months, and remains alive and under follow-up to date.