Top

Published in:

01-12-2013 | Original Article

Selecting patients during the “learning curve” of endoscopic Totally Extraperitoneal (TEP) hernia repair

Authors: N. Schouten, J. W. M. Elshof, R. K. J. Simmermacher, T. van Dalen, S. G. A. de Meer, G. J. Clevers, P. H. P. Davids, E. J. M. M. Verleisdonk, P. Westers, J. P. J. Burgmans

Published in: Hernia | Issue 6/2013

Abstract

Background

Totally Extraperitoneal (TEP) hernia surgery is associated with little postoperative pain and a fast recovery, but is a technically demanding operative procedure. Apart from the surgeon’s expertise, patient characteristics and hernia-related variations may also affect the operative time and outcome.

Methods

Patient-related factors predictive of perioperative complications, conversion to open anterior repair, and operative time were studied in a cohort of consecutive patients undergoing TEP hernia repair from 2005 to 2009.

Results

A total of 3,432 patients underwent TEP. The mean operative time was 26 min (SD ± 10.9), TEP was converted into an open anterior approach in 26 patients (0.8 %), and perioperative complications were observed in 55 (1.6 %) patients. Multivariable regression analysis showed that a history of abdominal surgery (OR 1.76, 95 per cent confidence interval 1.01–3.06; p = 0.05), and the presence of a scrotal (OR 5.31, 1.20–23.43; p = 0.03) or bilateral hernia (OR 2.25, 1.25–4.06; p = 0.01) were independent predictive factors of perioperative complications. Female gender (OR 5.30. 1.52–18.45; p = 0.01), a history of abdominal surgery (OR 3.96, 1.72– 9.12; p = 0.001), and the presence of a scrotal hernia (OR 34.84, 10.42–116.51, p < 0.001) were predictive factors for conversion. A BMI ≥ 25 (effect size (ES) 1.78, 95 % confidence interval 1.09–2.47; p < 0.001) and the presence of a scrotal (ES 5.81, 1.93–9.68; p = 0.003), indirect (ES 2.78, 2.05– 3.50, p < 0.001) or bilateral hernia (ES 10.19, 9.20–11.08; p < 0.001) were associated with a longer operative time.

Conclusion

Certain patient characteristics are, even in experienced TEP surgeons, associated with an increased risk of conversion and complications and a longer operative time. For the surgeon gaining experience with TEP, it seems advisable to select relatively young and slender male patients with a unilateral (non-scrotal) hernia and no previous abdominal surgery to enhance patient safety and ‘surgeon comfort’.

Dulucq JL, Wintringer P, Mahajna A (2009) Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years. Surg Endosc 23:482–486PubMedCrossRef

Lau H, Patil NG, Yuen WK (2006) Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males: a randomized trial. Surg Endosc 20:76–81PubMedCrossRef

Eklund A, Rudberg C, Smedberg S, Enander LK, Leijonmarck CE, Osterberg J (2006) Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair. Br J Surg 93:1060–1068PubMedCrossRef

Lal P, Kajla RK, Chander J, Saha R, Ramteke VK (2003) Randomized controlled study of laparoscopic total extraperitoneal versus open Lichtenstein inguinal hernia repair. Surg Endosc 17:850–856PubMedCrossRef

Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant AM (2005) Transabdominal pre-peritoneal (TAPP) vs. totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database Syst Rev 1:CD004703

Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikinnen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13:343–403CrossRef

Ou YC, Yang CR, Wang J, Yang CK, Cheng CL, Patel VR, Tewari AK (2010) The learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy by a single surgeon. BJUI Int 2:1–6

Lau H, Patil NG, Yuen WK, Lee F (2002) Learning curve for unilateral endoscopic totally extraperitoneal (TEP) inguinal hernioplasty. Surg Endosc 16:1724–1728PubMedCrossRef

Liem MS, van Steensel CJ, Boelhouwer RU, Weidema WF, Clevers GJ, Meijer WS (1996) The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair. Am J Surg 171:281–285PubMedCrossRef

10.

Aeberhard P, Klaiber C, Meyenberg A, Osterwalder A, Tschudi J (1999) Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC). Surg Endosc 13:1115–1120PubMedCrossRef

11.

Voitk AJ (1998) The learning curve in laparoscopic inguinal hernia repair for the community general surgeon. Can J Surg 41:446–450PubMed

12.

Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R, Dunlop D, Gibbs J, Reda D, Henderson W, for the Veterans Affairs Cooperative Studies Program (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350:1819–1827PubMedCrossRef

13.

Zendejas B, Onkendi EO, Brahmbhatt RD et al (2011) Long-term outcomes of laparoscopic totally extraperitoneal inguinal hernia repairs performed by supervised surgical trainees. Am J Surg 201(3):379–383PubMedCrossRef

14.

Schouten N, Simmermacher RK, van Dalen T, Smakman N, Clevers GJ, Davids PH, Verleisdonk EJ, Burgmans JP (2012) Is there an end of the “learning curve” of endoscopic totally extraperitoneal (TEP) hernia repair? Surg Endosc [Epub ahead of print]

15.

Langeveld HR, van’t Riet M, Weidema WF, Stassen LP, Steyerberg EW, Lange J, Bonjer HJ, Jeekel J (2010) Total extraperitoneal inguinal hernia repair compared with Lichtenstein (the LEVEL-Trial): a randomized controlled trial. Ann Surg 251(5):819–824

16.

Spitz JD, Arregui ME (2000) Sutureless laparoscopic extraperitoneal inguinal herniorrhaphy using reusable instruments: two hundred three repairs without recurrence. Surg Laparosc Endosc Percutan Tech 10:24–29PubMed

17.

Koch CA, Greenlee SM, Larson DR et al (2006) Randomized prospective study of totally extraperitoneal inguinal hernia repair: fixation versus no fixation of mesh. JSLS 10:457–460PubMed

18.

Kark AE, Kurzer M (2008) Groin hernias in women. Hernia 12:267–270PubMedCrossRef

19.

Lau H, Patil NG, Yuen WK (2003) A comparative outcome analysis of bilateral versus unilateral endoscopic extraperitoneal inguinal hernioplasties. J Laparoendosc Adv Surg Tech A 13(3):153–157PubMedCrossRef

20.

Gass M, Rosella L, Banz V, Candinas D, Güller U (2012) Bilateral total extraperitoneal inguinal hernia repair (TEP) has outcomes similar to those for unilateral TEP: population-based analysis of prospective data of 6505 patients. Surg Endosc 26:1364–1368PubMedCrossRef

21.

Dulucq JL, Wintringer P, Mahajna A (2006) Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or previous lower abdominal surgery. Hernia 9:228–230

22.

Elshof JWM, Keus F, Burgmans JPJ, Clevers GJ, Davids PHP, Van Dalen T (2009) Feasibility of right-sided total extraperitoneal procedure for inguinal hernia repair after appendectomy: a prospective cohort study. Surg Endosc 23(8):1754–1758PubMedCrossRef

23.

Koch A, Edwards A, Haapaniemi S, Nordin P, Kald A (2005) Prospective evaluation of 6895 groin hernia repairs women. Br J Surg 92:1553–1558PubMedCrossRef

24.

Rosemar A, Angeras U, Rosengren A, Nordin P (2010) Effect of body mass index on groin hernia surgery. Ann Surg 252:397–401PubMedCrossRef

25.

Lindstrom D, Sadr Azodi O, Belloco R (2007) The effect of tobacco consumption and body mass index on complications and hospital stay after inguinal hernia surgery. Hernia 11:117–123PubMedCrossRef

Title: Selecting patients during the “learning curve” of endoscopic Totally Extraperitoneal (TEP) hernia repair
Authors: N. Schouten
J. W. M. Elshof
R. K. J. Simmermacher
T. van Dalen
S. G. A. de Meer
G. J. Clevers
P. H. P. Davids
E. J. M. M. Verleisdonk
P. Westers
J. P. J. Burgmans
Publication date: 01-12-2013
Publisher: Springer Paris
Published in: Hernia / Issue 6/2013
Print ISSN: 1265-4906
Electronic ISSN: 1248-9204
DOI: https://doi.org/10.1007/s10029-012-1006-2

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Selecting patients during the “learning curve” of endoscopic Totally Extraperitoneal (TEP) hernia repair

Abstract

Background

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 6/2013

Mesh fixation with fibrin sealant during endoscopic totally extraperitoneal inguinal hernia approach: a review of 640 repairs

A rare complication from total extraperitoneal (TEP) laparoscopic inguinal hernia repair: bladder rupture associated with a balloon dissector

Incarcerated inguinal hernia and small bowel obstruction as a rare complication of a penile prosthesis

Obturator nerve injury in laparoscopic inguinal hernia mesh repair

Reply to: Invited comment “Chronic pain and quality of life after transinguinal preperitoneal (TIPP) inguinal hernia repair: a few tips on TIPP”. D.C. Chen and P. Amid. DOI 10.1007/s10029-013-1138-z

Quality of life change in elderly patients undergoing open inguinal hernia repair