DOI: 10.5604/01.3001.0014.8695 POL PRZEGL CHIR 2021: 93 (4): 11-14
originalarticle
11
Outcomes of Endoscopic Totally Extraperitoneal (TEP)
repair of clinically occult inguinal hernia diagnosed
with ultrasonography
Wyniki całkowicie pozaotrzewnowej endoskopowej (TEP) operacji
naprawczej w leczeniu niejawnej klinicznie przepukliny pachwinowej
rozpoznanej na podstawie badania ultrasonograficznego
Eyup Kebapcı
1, Safak Ozturk
2, Mutlu Unver
21Department of General Surgery, Tepecik Teaching and Research Hospital, Izmir, Turkey
2Department of General Surgery, Izmir Economy University Medicalpark Izmir Hospital, Izmir, Turkey
Article history: Received: 12.01.2021 Accepted: 05.05.2021 Published: 07.05.2021
ABSTRACT: Introduction: Inguinal hernias generally present with groin lump and pain. Although inguinal hernias can be diagnosed clinically in most cases, patients without a groin lump pose a considerable diagnostic challenge. The first-line diagnostic imaging tool in these cases is ultrasound (US) and the recommended surgical procedure is laparoscopic-endoscopic repair.
Aim: This retrospective study aims at evaluating postoperative results and complication rates of TEP technique in patients with occult contralateral hernias diagnosed with US in comparison to patients with clinically diagnosed hernias.
Methods: A retrospective study was conducted to evaluate the outcomes of TEP procedure in patients with radiologically diagnosed occult contralateral hernias in comparison to patients with clinically diagnosed hernias. All hernias included in this study were repaired by TEP technique and secured with an extraperitoneal mesh. Demographic data, patient characteristics and perioperative information were obtained by reviewing medical records.
Results: A total number of 109 patients were enrolled in the study. The majority of patients were male and the mean age was 48.9 ± 14.6 years. In 56 cases, hernias were repaired unilaterally, while the remaining 53 were repaired bilaterally. Right-sided hernias were more common than left-sided hernias. The morbidity rate was 7.1% in unilateral repairs and 3.8% in bilateral repairs. The recurrence rate was 3.6% for unilateral repairs and 5.7% for bilateral repair.
Conclusion: Some studies report that the incidence of clinical contralateral inguinal hernias identified after primary unilateral surgery is approximately 10%. If these contralateral hernias were diagnosed prior to the primary surgery, the risk of performing another operation could be avoided. Laparoscopic surgery enables bilateral hernia repair without any additional incisions, presenting similar morbidity rates when compared to unilateral repair. There was no significant difference between unilateral and bilateral TEP repair in terms of intraoperative and postoperative surgical complications. These results suggest that laparoscopic inguinal hernia repair is a safe and effective surgical technique for both unilateral and bilateral procedures. In order to prevent second operation, all patients with suspected inguinal hernia should undergo an US examination before surgery.
KEYWORDS: hernia repair, inguinal hernia, laparoscopy, ultrasonography
STRESZCZENIE: Wprowadzenie: Przepukliny pachwinowe objawiają się zazwyczaj jako obecność nieprawidłowej masy i bólu w okolicy pachwinowej. W większości przypadków można je rozpoznać w badaniu klinicznym, jednak pacjenci bez obecności guza w okolicy pachwinowej stanowią wyzwanie diagnostyczne. Narzędziem diagnostycznym stosowanym w pierwszej kolejności w tej grupie pacjentów jest badanie ultrasonograficzne (USG), a zalecany zabieg chirurgiczny to laparoskopowo-endoskopowa operacja naprawcza.
Cel: Celem niniejszego retrospektywnego badania jest ocena wyników pooperacyjnych i częstości występowania powikłań po zastosowaniu laparoskopowo-endoskopowej operacji naprawczej z techniką całkowicie pozaotrzewnową (TEP) u pacjentów z niejawnymi klinicznie przepuklinami rozpoznanymi na podstawie badania USG, przeciwstronnymi do obecności przepuklin rozpoznanych w badaniu klinicznym.
Metody: Retrospektywne badanie przeprowadzono w celu oceny wyników leczenia metodą TEP u pacjentów z niejawnymi klinicznie, przeciwstronnymi przepuklinami rozpoznanymi w badaniu obrazowym, u których obecna jest już przepuklina rozpoznana w badaniu klinicznym. Wszystkie zmiany operowano z zastosowaniem techniki TEP i zabezpieczono siatką umieszczoną pozaotrzewnowo. Dane demograficzne i charakterystykę pacjentów oraz dane dotyczące okresu okołooperacyjnego uzyskano z dokumentacji medycznej chorych.
Wyniki: Łącznie w badaniu wzięło udział 109 pacjentów; większość była płci męskiej. Średni wiek wynosił 48,9 ± 14,6 roku.
Przepukliny u 56 osób były operowane jednostronnie, natomiast u pozostałych wykonano operację obustronną. Przepukliny prawostronne występowały częściej niż przepukliny lewostronne. Zachorowalność to 7,1% dla operacji jednostronnych oraz 3,8%
dla operacji obustronnych. Częstość nawrotów wynosiła 3,6% dla operacji jednostronnych oraz 5,7% dla operacji obustronnych.
WWW.PPCH.PL
12
originalarticle
ABBREVIATIONS
PPV – predictive value
TAPP – Transabdominal Preperitoneal TEP – Totally Extraperioneal
US – ultrasound
INTRODUCTION
Inguinal hernias generally present with groin lump and pain [1].
Although inguinal hernias can be diagnosed clinically in most cases, patients without a groin lump pose a considerable diagnostic chal- lenge [2]. Since ultrasound (US) is a non-invasive and cheap imaging diagnostic technique, it is the examination of choice in these cases [1, 2]. International standard for inguinal hernia management is surgery [3]. The recommended surgical procedure is laparoscopic- endoscopic repair with the use of Transabdominal Preperitoneal (TAPP) or Totally Extraperioneal (TEP) technique [4]. Inguinal her- nia which does not present any symptoms on physical examination but is identified by means of radiological imaging instead, is called an occult inguinal hernia. The incidence of inguinal hernias detected by US is 9.5% [2]. The positive predictive value (PPV) of US in the diagnosis of occult hernia is between 94–100% [1]. In unilateral in- guinal hernia patients, the incidence of contralateral occult hernia ranges from 4.2% to 57.5% and the rate of progression to a symp- tomatic hernia is approximately 28% [5]. While some authors sug- gest performing prophylactic bilateral repair for unilateral hernias, this approach causes violation of the virgin space and results in addi- tional operation time and trauma [5]. This retrospective study aims at evaluating postoperative results and complication rates of TEP technique in patients with occult contralateral hernias diagnosed with US in comparison to patients with clinically diagnosed hernias.
MATERIALS AND METHODS
A retrospective study was performed to evaluate the outcomes of TEP procedure in patients with radiologically diagnosed occult contralateral hernias in comparison to patients with clinically di- agnosed hernias. A total number of 109 patients, who underwent an elective TEP procedure in the Department of General Surgery at the Medicalpark İzmir Hospital of the Izmir University of Eco- nomics between January 2019 and January 2020, were enrolled in this study. The eligibility criteria included patients with inguinal hernias diagnosed by means of both radiological and clinical ex- aminations. The only exclusion criterion was the presence of an in- carcerated hernia. All defects were repaired by TEP technique and secured with an extraperitoneal mesh. All patients were discharged from hospital after the 1st postoperative day.
Demographic data, patient characteristics and preoperative infor- mation were obtained by reviewing medical records. Age, gender, hernia side, type of diagnosis (clinical or radiological), operation time, testicular pain, involvement of scrotal compartment, length of hospital stay, morbidity and recurrence rates were analyzed. Ethical approval was obtained by Thai Clinical Trial Registry and the iden- tification number TCTR20200826006 was assigned.
STATISTICAL ANALYSIS
Data analysis was performed by using IBM SPSS Statistics software version 17.0 (IBM Corporation, Armonk, NY, USA). The distributions of continuous variables were determined by Kolmogorov-Smirnov test. The assumption of homogeneity of variances was analyzed with the use of Levene test. Descriptive statistics for continuous vari- ables were expressed as mean ± SD or median (min-max), wher- ever appropriate. Numbers of cases and percentages were used for categorical data. While the mean differences between groups were compared by Student’s t-test, Mann-Whitney U test was applied to compare continuous variables with unmet parametrical test as- sumptions. Categorical data were evaluated by continuity-corrected χ2 or Fisher's exact test, wherever applicable. A P-value lower than 0.05 was considered statistically significant.
RESULTS
Patient demographic data and characteristics are summarized in Tab. I. A total number of 109 patients were enrolled in the study.
The majority of patients were male and the mean age was 48.9
± 14.6 years. In 56 cases hernias were repaired unilaterally, while the remaining 53 were repaired bilaterally. Right-sided hernias were more common than left-sided hernias. The outcomes of unilater- al and bilateral repairs are shown in Tab. II. The mean duration of surgery was 54.5 min in unilateral hernias and 86 min in bilateral hernias. The morbidity rate was 7.1% in unilateral repairs and 3.8%
in bilateral repairs, which occurred to be statistically insignificant with a P-value of 0.679. The recurrence rate was 3.6% in unilateral repairs and 5.7% in bilateral repairs, which was also statistically in- significant with a P-value of 0.673.
DISCUSSION
Some studies report that the incidence of clinical contralateral in- guinal hernias identified after primary unilateral surgery is approxi- mately 10%. If these contralateral hernias were diagnosed prior to primary surgery, the risk of a second operation could be avoided.
Laparoscopic surgery enables bilateral hernia repair without any Wnioski: W niektórych badaniach opisywana częstość występowania klinicznie jawnej przeciwstronnej przepukliny pachwinowej po pierwszym operacyjnym leczeniu jednostronnej przepukliny wynosi około 10%. Gdyby możliwe było rozpoznanie przepukliny przeciwstronnej przed pierwszą operacją, można by uniknąć ryzyka związanego z drugą operacją.
Chirurgia laparoskopowa umożliwia obustronną operację naprawczą przepukliny bez wykonywania dodatkowych nacięć przy podobnej zachorowalności. Nie stwierdzono istotnej różnicy pomiędzy operacjami jednostronnymi a obustronnymi metodą TEP w zakresie śródoperacyjnych i pooperacyjnych powikłań. Wyniki te sugerują, że laparoskopowa operacja naprawcza przepukliny pachwinowej jest bezpieczną i skuteczną techniką operacyjną, zarówno w przypadku operacji jednostronnej, jak i dwustronnej.
W celu zapobiegania drugiej operacji wszyscy pacjenci z podejrzeniem przepukliny pachwinowej powinni zostać poddani USG.
SŁOWA KLUCZOWE: laparoskopia, operacja naprawcza przepukliny, przepuklina pachwinowa, ultrasonografia
13
POL PRZEGL CHIR 2021: 93 (4): 11-14
originalarticle
N = 109
Age (Year) 48.9 ± 14.6
Range (year) 18–84
Gender
Male 104 (95.4%)
Female 5 (4.6%)
Side
Unilateral 56 (51.4%)
Bilateral 53 (48.6%)
Side detected on clinical examination
Righ 61 (56.0%)
Left 25 (22.9%)
Bilateral 23 (21.1%)
Operation Time (minute) 65.0 (23.0–210.0)
Testicular Pain 24 (22.0%)
Scrotal Compartment 2 (1.8%)
Morbidity 6 (5.5%)
Seroma 4 (3.7%)
Hematoma 1 (0.9%)
Hydrocele 1 (0.9%)
Hospital Stay (Day) 1.0 (1.0–1.0)
Recurrence 5 (4.6%)
UNILATERAL (N = 56) BILATERAL (N = 53) P-VALUE
Age (Year) 49.4 ± 15.4 48.4 ± 13.8 0.734†
Gender 0.364‡
Male 52 (92.9%) 52 (98.1%)
Female 4 (7.1%) (1.9%)
Operation Time (Minute) 54.5 (23.0–180.0) 86.0 (40.0–210.0) <0.001¶
Testicular Pain 13 (23.2%) 11 (20.8%) 0.937$
Scrotal Compartment 1 (1.8%) 1 (1.9%) N/A
Morbidity 4 (7.1%) 2 (3.8%) 0.679‡
Seroma 2 (3.6%) 2 (3.8%) >0.999‡
Hematoma 1 (1.8%) 0 (0.0%) N/A
Hydrocele 1 (1.8%) 0 (0.0%) N/A
Recurrence 2 (3.6%) 3 (5.7%) 0.673‡
Tab. I. Demographic data and baseline characterictics.
Tab. II. Demographic and surgery-related parameters.
additional incisions, presenting similar morbidity rates when com- pared to unilateral repair [6]. Several surgical techniques have been described. The most common procedures were TAPP and TEP. Both techniques involved mesh placement in the preperi- toneal space. However, TAPP repair has a major advantage, as it
allows surgeons to explore the contralateral side without any ad- ditional dissection, while TEP repair requires performing another dissection for successful diagnosis [7]. In our study, the contralat- eral hernia identification rates in TAPP and TEP procedures were 11% and 13%, respectively [8, 9]. There was no difference between
† Student’s t test, ‡ Fisher’s exact test, ¶ Mann-Whitney U test, $ Continuity corrected χ2 test, N/A: Not applicable.
WWW.PPCH.PL
14
originalarticle
TAPP and TEP procedure in terms of the recurrence rate [10].
Since lipomas can mimic recurrences after hernia repair, herni- ated retroperitoneal fat tissue must be removed during surgery [11, 12]. There was no significant difference between unilateral and bilateral TEP repair in terms of intraoperative and postopera- tive surgical complications [4, 5]. Current guidelines recommend performing US examination before hernia repair surgery, espe- cially in order to identify occult inguinal hernias [3]. There is no clear advice for clinical examination in occult inguinal hernias [2].
Inguinal US and diagnostic laparoscopy may be better than ex- ploration of contralateral inguinal region in TEP procedures in cases of occult contralateral inguinal hernias [5]. In our study,
we used US routinely before surgery and performed bilateral TEP repair for patients with occult inguinal hernia diagnosed with US.
The morbidity rate was 7.1% in unilateral repairs and 3.8% in bi- lateral repairs. There was no significant difference in terms of the recurrence rate – it was 3.6% in unilateral repairs and 5.7% in bi- lateral repairs.
Our results suggest that laparoscopic inguinal hernia repair is a safe and effective surgical technique for both unilateral and bi- lateral surgical procedures. In order to prevent second operation, all patients with suspected inguinal hernia should undergo an US examination prior to surgery.
6. Wu C.C., Chueh S.C., Tsai Y.C.: Is contralateral exploration justified in endoscopic total extraperitoneal repair of clinical unilateral groin hernias – A Prospective cohort study. Int J Surg., 2016; 36: 206–211.
7. Dulucq J.L., Wintringer P., Mahajna A.: Occult hernias detected by laparo- scopic totally extra-peritoneal inguinal hernia repair: a prospective study.
Hernia., 2011; 15: 399–402.
8. Sayad P., Abdo Z., Cacchione R., Ferzli G.: Incidence of incipient contralateral hernia during laparoscopic hernia repair. Surg Endosc., 2000; 4(6): 543–545.
9. Koehler R.H.: Diagnosing the occult contralateral inguinal hernia. Surg Endosc., 2002; 16(3): 512–520.
10. Köckerling F.: TEP for elective primary unilateral inguinal hernia repair in men: what do we know? Hernia., 2019; 23: 439–459.
11. Roos M.M., Van Hessen C.V., Verleisdonk E.J.M.M. et al.: An 11-year analysis of reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high volume hernia center. Hernia., 2019; 23: 655–662.
12. Lau H., Loong F., Yuen W.K., Patil N.G.: Management of herniated retro- peritoneal adipose tissue during endoscopic extraperitoneal inguinal her- nioplasty. Surg Endosc., 2007; 21(9): 1612–1616.
REFERENCES
1. Alabraba E., Psarelli E., Meakin K. et al.: The role of ultrasound in the mana- gement of patients with occult groin hernias. Int J Surg., 2014; 12(9): 918–922.
2. Roos M.M., Verleisdonk E.M.M., Sanders F.B.M. et al.: EFFECT study group.
Effectiveness of endoscopic totally extraperitoneal (TEP) hernia correction for clinically occult inguinal hernia (EFFECT): study protocol for a randomized controlled trial. Trials., 2018; 19(1): 322–328.
3. Van Hout L., Bökkerink W.J.V., Ibelings M.S., Heisterkamp J., Vriens P.W.H.E.:
Outcomes of surgery on patients with a clinically inapparent inguinal hernia as diagnosed by ultrasonography. Hernia., 2018; 22(3): 525–531.
4. Köckerling F., Schug-Pass C., Adolf D., Keller T., Kuthe A.: Bilateral and Uni- lateral Total Extraperitoneal Inguinal Hernia Repair 8TEP) have Equivalent Early Outcomes: Analysis of 9395 Cases. World J Surg., 2015; 39: 1887–1894.
5. Chiang C.C., Yang H.Y., Hsu Y.C.: What happens after no contralateral explo- ration in total extraperitoneal (TEP) herniography of clinical unilateral ingu- inal hernias?. Hernia., 2018; 22: 533–540.
Word count: 1551 Page count: 4 Tables: 2 Figures: – References: 12 10.5604/01.3001.0014.8695 Table of content: https://ppch.pl/issue/13873
Some right reserved: Fundacja Polski Przegląd Chirurgiczny. Published by Index Copernicus Sp. z o. o.
The authors declare that they have no competing interests.
The content of the journal „Polish Journal of Surgery” is circulated on the basis of the Open Access which means free and limitless access to scientific data.
This material is available under the Creative Commons – Attribution-NonCommercial 4.0 International (CC BY-NC 4.0).
The full terms of this license are available on: https://creativecommons.org/licenses/by-nc/4.0/legalcodeode
Safak Ozturk MD; Department of General Surgery, Izmir Economy University Medicalpark Izmir Hospital, Izmir; Yeni Girne Bulvarı, 1825 sokak No 12 Karsıyaka, Izmi, Turkey; Phone: +90 5053131845; E-mail: surgeon0052@gmail.com
Kebapci E., Ozturk S., Unver M.: Outcomes of Endoscopic Totally Extraperitoneal (TEP) repair of clinically occult inguinal hernia diagnosed with ultrasonography; Pol Przegl Chir 2021; 93(4): 11-14
DOI:
Copyright:
Competing interests:
Corresponding author:
Cite this article as:
