Page 20 - World Journal of Laparoscopic Surgery

Study of Selection of Method of Laparoscopic Inguinal Hernia Repair
the peritoneal flap. In our observation low incidence is mainly Table 18: Recurrence
due to meticulous dissection during surgery, packing with gauze Recurrence Current study (%) MRC trial (%)
pieces at the hernial defect site, and strapping with dynaplast to
decrease the potential space for seroma collection. We can also Laparoscopic repair 0 1.9
prevent seroma formation by tucking pseudosac to the posterior
abdominal wall with tacker and decreasing the potential space for Hence, there is evidence as per our study that laparoscopic
seroma formation. We observed more seroma formation in TAPP surgeries show significant differences in both postoperative and
which is about 3% out of the 4% of indirect hernia patients in our persistent pain.
study mainly because of excessive dissection and pulling of the
indirect hernial sac from the deep ring making it difficult to do Recurrence
hemostasis beyond deep ring which may be the cause. No active In our study, we found 0% recurrence in laparoscopic hernia repair
management is required for seroma. The seroma usually subsides cases. MRC laparoscopic hernia trial group found a 1.9% recurrence
within a month. We advise never to aspirate the seroma as it may rate in the laparoscopic group. Results of recurrence are comparable
introduce infection from outside into the seroma. for both TEP and TAPP in our study (Table 18). The most common
A total of 2% of our patients developed scrotal edema reason for recurrence is improper dissection and separation of the
postoperatively in TAPP, and none of our TEP patients had hernial sac which might cause its inadequate reduction or other
developed scrotal edema. Mainly observed in patients with additional defects or hernias may be missed. Incomplete mesh
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large complete indirect hernial defects; as such defects require placement as in not covering the defect completely, the small
excessive dissection and mobilization and the indirect sac can size of mesh or not taking into account the contraction of mesh is
be dissected more meticulously by TEP as compared to TAPP another major reason for recurrence. It is now generally believed
according to our experience. No active management is required. that the mesh size should be at least 10 cm × 14 cm to cover all of
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The edema usually subsides within a month. We have prescribed the potential hernia sites, to provide at least 4-cm overlap with the
chymotrypsin–trypsinogen and serratiopeptidase combination for hernia, and to avoid problems with mesh migration, shrinkage, and
oedema treatment. rolling. We kept 12 cm × 15-cm-sized mesh in both TEP and TAPP.
In our study, 4% of the cases experienced shoulder pain in TAPP,
which may be due to diaphragmatic irritation caused by carbon Duration of Hospital Stay
dioxide insufflation to create pneumoperitoneum, and this minor The mean duration of the hospital was found to be 2.17 days for
complication is never faced in TEP as pneumo preperitoneum is the laparoscopic inguinal hernia repair. Since ours is a teaching
created rather than pneumoperitoneum. institution the minimum time taken from admission to surgery is
Mesh infection is also a troublesome complication that requires around 1 day hence making the duration of stay apparently longer.
the removal of the mesh. Mycobacterium other than tuberculosis Choi et al. had a mean hospital stay of 1.4 days for the laparoscopic
3
(MOTT) can be cultured from infected mesh. Luckily, we did not method. Similarly, Phillips et al. in their study found a mean stay
encounter this kind of complication in our study because the mesh
and mesh fixation devices used were sterilized by ethyline oxide of 1.91 days for the laparoscopic method. This shows, there is
sterilisation (ETO), and we usually take laparoscopic hernia as the decreased hospital stay in laparoscopic surgery. The mean duration
first operation in our operative list to prevent infection. of hospital stay in our study for TEP was 2.1 and for TAPP was 2.24.
it is showing no major difference in hospital stay for TEP vs TAPP.
Postoperative Pain
In our study, postoperative pain at 1 week of surgery was 26% Cost of Surgery
which was of mild grade that is P1 according to VAS score in both The increased cost of surgery is a major drawback of laparoscopic
TEP and TAPP laparoscopic repair method. No significant difference hernia repair, and this increased cost is due to more expensive

was found according to the SCUR trialfor graded pain scores on the equipment, longer operative time, and more operative charges
7-day postoperative visit. During this visit, 72% of patients in the claimed by surgeons. Accurate evaluation of operative cost based
laparoscopic group, reported no pain. The veterans affairs (VA) trial on the type of procedure (TEP/TAPP), type and length of anesthesia,
found significantly less pain on the day of the operation and at 2 and the number of tackers used to fix the mesh. Laparoscopic
weeks in both TEP and TAPP methods by using a VAS. instruments require a special sterilization technique (ETO), which
Chronic pain is sometimes a debilitating complication for the also increases the cost. In the case of TAPP if the peritoneum flap
patient and a more difficult problem for the surgeon to treat than is closed by the tackers, then as compared to TEP cost of surgery
perioperative pain and also the spectrum of severity is wide. Hence, increases, and if the peritoneum flap is closed by intracorporeal
this makes it more important for successful inguinal hernia repair. suturing then the length of surgery will increase so in this domain
In our study, postoperative pain at 3 months of surgery was TEP is better compared to TAPP.
found in only two patients (2%) in TAPP cases for which we could
not find any reasons. None of our TEP patients had postoperative
pain post 3-months follow-up. The laparoscopic group in the MRC conclusIon
trial, at 1 year after the operation, had a significantly lower rate of The TAPP repair is useful in special circumstances like when there is
persistent groin pain. In the VA trial, incidence of neuralgia or other diagnostic uncertainty if a hernia is present or not in a patient whose
pain post 1 year after the operation was 9.8% in the laparoscopic history and physical examination are unclear also in uncomplicated
group. Significantly a smaller number of cases of pain persisting irreducible hernias or large-sized hernias. We can also look for the
post 1 year of either surgery was found according to The European undiagnosed opposite-site hernia in TAPP as compared to TEP.
Union meta-analysis. 8 Also, TAPP is preferred over TEP in patients with a hernia who have

World Journal of Laparoscopic Surgery, Volume 16 Issue 1 (January–April 2023) 19