Page 21 - Journal of Laparoscopic Surgery

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A Comparative Randomized Parallel Group Study between the Classical TAPP Repair and Modified TAPP
in view of statistically calculated minimum sample size the incidence was 7.69% (95% CI; 1-14%), whereas, in the
chosen at the beginning. Mean follow-up was 628 days with control group, the incidence was 15.38% (95% CI; 7-24%).
range between 435 and 797 days. Operating time and corres- However, with a p-value of 0.164, this observed difference
ponding standard deviation of different techniques are shown lost statistical significance. Majority of seromas developed
in Figure 3. The mean operating time in the study and control within couple of weeks and detected in follow-up visit
groups were 65.15 (50-90 mins) and 76.64 minutes (55- 1 month after surgery and resolved spontaneously by 3rd
95 mins) respectively. p-value of < 0.0001 calculated from month. Fourteen out of total 15 incidences of postoperative

t-score of 7.294. There were no intraoperative complication, seroma, developed following repair of direct hernia (IIIA)
need for readmission or re-exploration and hospital mortality treated by either method.
in either group. Table 2 summarizes the postoperative compli- Regarding postoperative chronic pain, the overall
cations, while Table 3 illustrates comparison of techniques incidence was 8.46% (95% CI; 3-13%) (n = 11). In the
on analgesic requirement, hospital stay and time for return study group, it was 3% (95% CI; 0-7%) (n = 2) in contrast
to work. Table 4 demonstrates cost effectiveness of the to higher incidence in the control group of 13.84% (95% CI;
modified technique comparing against major variants that 5-22%) (n = 9). p-value of 0.0071 denotes significance of
determine effective cost of a procedure. No wound or mesh difference. One interesting finding was very high incidence
infection was reported in any patient. The study group had of chronic pain when hernia tacker was used to fix the mesh
significantly lower incidence of seroma. Overall incidence with Cooper’s ligament and for closure of peritoneum.
of seroma was 11.53% (95% CI; 6-17%). In study group, Incidence was 29% (95% CI; 12-47%) (n = 8). Majority
of chronic pain presented at 6 months follow-up visit
(10/11), and had a slightly protracted course and resolved
in all but two patients by 1 year follow-up. Two patients
continued to have pain ever after a year, despite analgesics
and neuromodulating medications and at present being
cared for by pain clinic specialists. Chronic pain bore no
relation with initial analgesic requirement at home after
discharge.
Five patients developed vaginal hydrocele, all detected
at 3 months follow-up visit and progressed to increased size
and discomfort over time and had to be treated by surgery
subsequently. On all occasions, TAPP was done for indirect
hernia with high ligation of sac.
Ultrasound (US) was done on 40 separate instances in
Fig. 3: Operating time with standard deviation in minutes with 34 patients in the follow-up period for investigation of post-
different techniques of TAPP repair
operative seroma, chronic pain, vaginal hydrocele, abdo-
Table 2: Postoperative complications minal pain and identifying recurrence of hernia. On two
Complication Modified TAPP Classical TAPP p-value occasions when US could not conclusively eliminate recur-
(n = 65) (n = 65) rence in patients with chronic pain, computed tomography
No. (%) No. (%)
Seroma 5 (7.69) 10 (15.38) 0.168* (CT) of involved groins was performed which successfully
Chronic pain 2 (3.07) 9 (13.84) 0.007* excluded recurrence on both occasion.
Vaginal hydrocele 2 (3.07) 3 (4.61) 1** Average time taken for peritoneal closure by suturing was
*p-value from Z score; **Fisher’s exact test 12 minutes. Mean duration of follow-up has been 628 days.

Table 3: Comparison of techniques on analgesic requirement, hospital stay and time for return to work
Group Patient and technique Analgesic requirement (gm) Hospital stay in days Return to normal work (days)
mean (range) mean (range) mean (range)
A All TAPP repair (n = 65) 21.86 (12-28) 2.10 (1-3) 17.87 (11-30)
B Both sides by classical 20.16 (12-28) 2 (1-3) 17.875 (14-30)
TAPP (n = 18)
C At least one side by 22.59 (12-28) 2.14 (1-3) 17.78 (11-26)
modified TAPP (n = 47) p-value when compared to
A B A B A B
0.468 0.096 0.597 0.181 0.896 0.934
World Journal of Laparoscopic Surgery, January-April 2014;7(1):16-22 19