European Journal of Cardiovascular Medicine

Hernia surgeries, encompassing both inguinal and ventral/incisional types, rank among the most frequently performed surgical procedures globally. The past half-decade has witnessed a remarkable evolution in hernia surgery, propelled by advancements in surgical techniques and the proliferation of mesh technologies. This heightened focus on hernia management has enhanced research quality and outcomes, offering refined strategies for addressing both straightforward and complex hernia cases. The advent of novel techniques and mesh products has reignited interest in hernia surgery within the surgical and plastic surgery communities. ¹

The inception of laparoscopic inguinal hernia repair closely followed the establishment of laparoscopic cholecystectomy as the standard treatment for cholelithiasis. Despite this, laparoscopic hernia repair has been a subject of ongoing debate within the surgical fraternity. Initial laparoscopic methods, which involved plugging or stapling the internal ring, were quickly deemed ineffective due to high recurrence rates. Subsequently, the pre-peritoneal placement of mesh, inspired by Stoppa's open procedure, emerged as a more viable technique. In 1984, Lichtenstein et al. introduced the concept of "Tension-Free Hernioplasty," advocating for the routine use of mesh in hernia repairs and rendering tissue repairs obsolete. The early 1990s saw a surge in the popularity of laparoscopic tension-free mesh repair, with preliminary studies suggesting its superiority over traditional open repairs in terms of postoperative pain, quicker resumption of normal activities, and expedited return to work. However, the real controversy began in 1990 with the advent of laparoscopic Tension-Free repair, which was aggressively marketed for its purported benefits, often overlooking significant details. ^[1-3]

Evidence-based medicine remains the most scientific approach to evaluating the superiority of one surgical method over another. It is imperative to compare laparoscopic mesh repairs with their open mesh counterparts, as comparing them with open tissue repairs would yield invalid conclusions.

The study encompasses all cases of primary uncomplicated unilateral direct or indirect inguinal hernia operated in the elective theatre at the Upgraded Department of Surgery, Osmania Medical College over a 10-month period from November 2020 to August 2021. A total of 50 patients were included, with 25 cases each of open hernioplasty and TAPP. The study employed a single-centre prospective design, with data collection focusing on intraoperative complications, postoperative pain (measured using the Visual Analog Scale), and other postoperative complications. The duration of hospital stay was also recorded.

Statistical Analysis

Data analysis was conducted using IBM SPSS Statistics software version 24.0. Descriptive statistics, frequency analysis, and percentage analysis were utilized for categorical variables, while mean and standard deviation were used for continuous variables. The Chi-Square test was used for categorical data, with a probability value of 0.05 considered significant.

This study aims to contribute valuable insights into the comparative efficacy and safety of TAPP versus Lichtenstein tension-free open hernioplasty, thereby guiding surgical practice in the management of primary inguinal hernias.

The age distribution of the subjects ranged from 26 to 70 years. The mean age of patients subjected to the TAPP group was around 46 years. However, the mean age for Lichtenstein repair was 49 years. Elderly patients were preferred for Lichtenstein tension due to the risks of subjecting to general anaesthesia.

2. Diagnosis

Each of the cases were clinically examined and diagnosed as per the European Hernia Society classification.

Among the 25 cases studied that underwent Lichtenstein were 8 left-sided inguinal hernia, 17 right inguinal hernia. And 6 and 19 respectively with TAPP Procedure. Although all hernias were preoperatively evaluated, most of the diagnosis on the type of the hernia was made intraoperatively.

3. Operative time.

The mean operative time was (106.40 ±11.504) minutes for TAPP, (55.00 ±8.416) minutes for open Lichtenstein repair.

The duration of surgery was observed to be longer for laparoscopic hernia repair when compared with Lichtenstein tension-free open hernioplasty. The laparoscopic hernioplasty TAPP took an average of 106 minutes.

The postoperative pain was measured using Visual Analog Scale (VAS) 6 hours after the surgery. The patient was given a dose of Injection Tramadol 100mg in after the surgery. The next dose of analgesic was given based on the VAS score. The pain scores were analysed with Chi-square and the difference found to be statistically significant. Lichtenstein tension-free open hernioplasty was found to have increased post-operative pain when compared to laparoscopic repair.

Antoniou et al.⁴ stated that the repair of inguinal hernia is one of the most globally performed surgical procedures. Lichtenstein repair is the most common technique done for repair. Nonetheless, in the last years laparoscopic technique for repair of inguinal hernia is technically demanded mainly as (TAPP) technique. Claus et al. [9] mentioned that TAPP approach necessitates the minimally invasive surgery benefits, like pain relieve as well as early recovery.

4.1. Operative time

Simons et al. ⁵ demonstrated that the median operative time was moderately elevated in the TAPP as compared to the open Lichtenstein repair technique (110.3 vs. 97.1 min; p =0.23).

In laparoscopic TAPP repair, the use of partially absorbable mesh is better than the use of nonabsorbable mesh regarding postoperative pain and time needed to return to routine daily activities, but was accompanied with longer operative time ⁶.

In the present study, the mean operative time was (106.40 ±11.504) minutes for TAPP, (55.00 ±8.416) minute for open Lichtenstein repair. It can be attributed to the small sample size in this study.

4.2. Intra-operative complications

Neumayer et al. ⁷ illustrated that intra-operative complications were more in a laparoscopic procedure. Indeed, the skills of surgeons in laparoscopic repair make a difference. Also, spermatic cord structures demonstrated less that injured in TAPP compared to the open method, possibly due to the laparoscopic view which is magnified. In this study, none of the recruited subjects experienced intra-operative complications. This can be attributed to the small sample size in our study.

4.3. Post-operative complications

Grant ⁸ displayed substantially more diminished wound infection occurrence as well as hematoma along with elevated occurrence of seromas following laparoscopic repair.

In our study, there was no patients with wound infection (0%), two patients with seroma (8%), no patients with hematoma (0%), for TAPP repair in contrast to 6 seroma cases (24%), two patients with hematoma (8%) and five patients with wound infection (20%); however, no marked differences were detected between both groups.

4.4. Hernia recurrence

Schmedt et al.⁹ found a more elevated recurrence rate after the endoscopic repair. In our study, there were no substantial differences in terms of hernia recurrence, which may be due to the short period of follow up and the small number of patients.

4.5. Post-operative pain

Wennergren et al.⁹ stated that laparoscopic inguinal hernial repair is correlated with more releiving early post-operative pain in contrast to the open Lichtenstein repair. Wijerathne et al. ¹⁰ clarified that complications as well as postoperative pain are significantly correlated. In addition, less post-operative pain may be attributed to fewer complications, which are associated with this approach. TAPP repair was associated with earlier toleration of oral feeds, lesser post-operative pain, earlier discharge from the hospital, earlier return to usual activities, and less persisting pain ¹¹. Our study detected less postoperative pain day 0, day 1 as well as post-operative day 7 in TAPP repair with a highly significant P value. There was a significant difference 1 week post-operatively. One limitation to this work is the relatively small sample size. Another limitation is the relatively short follow up period of 1 week with the possibility of missing long-term cumulative benefit of the surgery.

Our study showed that TAPP repair of inguinal hernia is safer with less early post-operative pain. Also, it has fewer complications, with a significantly longer operative time.

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2. Jamil M, Niaz K, Tahir F, Sobia H. Laparoscopic trans-abdominal preperitoneal versus Lichtenstein repair of inguinal hernia: A comparative study. Prof Med J [Internet]. 2019 [cited 2024 May 13];26(07):1151– Available from: https://www.semanticscholar.org/paper/8e8a780aa5b9bb190004baaefe4cb1cadafda2ba
3. Shah MY, Raut P, Wilkinson TRV, Agrawal V. Surgical outcomes of laparoscopic total extraperitoneal (TEP) inguinal hernia repair compared with Lichtenstein tension-free open mesh inguinal hernia repair: A prospective randomized study. Medicine (Baltimore) [Internet]. 2022 [cited 2024 May 13];101(26):e29746. Available from: http://dx.doi.org/10.1097/md.0000000000029746