|Year : 2022 | Volume
| Issue : 2 | Page : 77-82
Outcomes after laparoscopic transabdominal preperitoneal (TAPP) hernia repair in the emergency: A matched case-control study
Ayelen Andrea Olivero, María Agustina Casas, Cristian Agustin Angeramo, Francisco Schlottmann, Emmanuel Ezequiel Sadava
Department of Surgery, Division of Abdominal Wall Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
|Date of Submission||09-Jan-2022|
|Date of Decision||29-Mar-2022|
|Date of Acceptance||31-Mar-2022|
|Date of Web Publication||19-May-2022|
Mr. Emmanuel Ezequiel Sadava
Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon 1640, C1118AAT, Buenos Aires
Source of Support: None, Conflict of Interest: None
Introduction: Laparoscopic repair of groin hernia (LRGH) is widely accepted for elective cases, but its use in emergency cases remains controversial. We aimed to compare postoperative outcomes between elective and emergent transabdominal preperitoneal (TAPP) repairs. Materials and Methods: Patients undergoing emergent LRGH (EM-LR) using a TAPP technique between June 2014 and December 2019 were included for analysis. A case-control cohort of patients undergoing elective LRGH (EL-LR) in the same period was identified and matched (1:3) on gender, age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, active smoking, and hypertension. Preoperative variables and postoperative outcomes were compared between both groups. Results: A total of 15 EM-LR were matched with 45 EL-LR. In patients undergoing EM-LR, the median time from onset of symptoms to surgery was 12 (1–168) h. No differences were found regarding the operative time (EM-LR: 107 min vs. EL-LR: 117 min, P = 0.37) and hernia defect size (EM-LR: 3.6 cm vs. EL-LR: 4.1 cm, P = 0.48). Although small bowel obstruction was observed in all emergent cases, no patients required enterectomy. Emergent cases were performed more frequently by specialist surgeons (EM-LR: 87% vs. EL-LR: 24%, P < 0.001). Mean hospital stay was 3.1 and 0.3 days after EM-LR and EL-LR, respectively (P < 0.001). Overall 30-day morbidity was similar between groups (EM-LR: 6.6% vs. EL-LR: 4.4%, P = 0.43). After a mean follow-up of 28.2 months, no recurrence was observed. Conclusion: EM-LR had similar overall morbidity and recurrence rates than elective repairs. Prompted surgical exploration and use of laparoscopy should be encouraged for the management of complicated inguinal hernias.
Keywords: Complicated hernia, emergency, groin hernia repair, laparoscopic surgery
|How to cite this article:|
Olivero AA, Casas MA, Angeramo CA, Schlottmann F, Sadava EE. Outcomes after laparoscopic transabdominal preperitoneal (TAPP) hernia repair in the emergency: A matched case-control study. Int J Abdom Wall Hernia Surg 2022;5:77-82
|How to cite this URL:|
Olivero AA, Casas MA, Angeramo CA, Schlottmann F, Sadava EE. Outcomes after laparoscopic transabdominal preperitoneal (TAPP) hernia repair in the emergency: A matched case-control study. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2022 Jul 1];5:77-82. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/2/77/345509
| Introduction|| |
Groin hernia repair is one of the most common procedures in general surgery, with more than 800,000 operations performed annually in the United States. The laparoscopic approach has shown a reduction in wound morbidity, faster recovery, and similar recurrence rate in comparison with open hernia repair. Although international guidelines recommend the laparoscopic repair of groin hernia (LRGH) for elective cases,, the role of laparoscopy for repairing an inguinal hernia in the emergency setting remains elusive. Previous researches have shown promising results on the feasibility of LRGH in the emergency,, although its efficacy needs further investigation. In addition, laparoscopic approach offers several advantages over open approach, such as greater diagnostic value, and a reduction in laparotomies, wound infection, and bowel resection rates.
The risk of complications in inguinal hernias (i.e., intestinal incarceration or strangulation) varies from 0.29% to 2.9%. Despite being relatively uncommon, complicated inguinal hernia represents the second cause of bowel obstruction in patients without a history of previous operations. Historically, the open Lichtenstein procedure has been suggested for emergent cases. In the last decades, the laparoscopic approach has gained popularity and has become an attractive alternative for emergency repairs. Complete evaluation of the abdominal cavity, reduction of hernia content under vision, and the possibility of hernia repair are some of the advantages of the minimally invasive approach. On the contrary, bowel distension and lack of extensive training in laparoscopic hernia surgery are potential challenges.
To date, scarce data are available regarding outcomes after laparoscopic repair of complicated inguinal hernias. Therefore, we aimed to compare postoperative outcomes between elective and emergency LRGHs.
| Materials and Methods|| |
This article respects the ethical principles for medical investigation on human beings stated in the Helsinki Declaration of 1975, as revised in 2000.
Study design and population
A retrospective study based on a prospectively collected database was performed. All patients who underwent emergency groin hernia repair between January 2014 and December 2019 were included for the analysis. The exclusion criteria of the study were as follows: hernia repair performed by an open approach, pediatric population, and hemodynamically unstable patients.
The sample was divided into two groups: patients who underwent laparoscopic groin hernia repair in the emergency setting (EM-LR) and patients with an elective groin hernia repair (EL-LR). Complicated inguinal hernia was defined as incarceration or strangulation based on clinical findings and image studies such as ultrasound or computed tomography (CT). To minimize heterogeneity between cohorts, the study group was case-matched 1:3 to a control population undergoing EL-LR. The following variables were selected for matching: age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and defect size. In complicated inguinal hernias, the time elapsed between onset of symptoms and the operation was recorded. A surgeon who already completed the learning curve for laparoscopic transabdominal preperitoneal (TAPP) repair, performing at least 30 LR per year, was defined as a specialist surgeon.
The institutional review board (IRB) approved this study. Written informed consent was waived by the IRB owing to the study’s retrospective nature.
Intravenous antibiotics were administered 30 min before surgical incision in all patients. The first step in the laparoscopic approach was the reduction of the hernia content. In most cases, it was achieved with a combined maneuver of gentle traction with grasper and pushing back the bowel from the outside. An enlargement of the hernia ring through a medial incision in direct and femoral hernias (lacunar ligament) or a lateral incision in indirect hernias was performed when reduction was not straightforward. After complete reduction, the bowel loops were irrigated with warm saline solution and their vitality was assessed. Afterwards, the TAPP repair was performed as previously described. Briefly, the peritoneum was incised to access the preperitoneal space. Hernia sac was reduced, and the lower epigastric vessels and elements of the spermatic cord or round ligament were identified. Dissection was completed when a critical view of the myopectineal orifice was achieved. A flat piece of polypropylene mesh was placed in all cases for reinforcement, and it was fixed to the Cooper’s ligament, transverse abdominis, and rectus abdominis muscles with absorbable tacks. Peritoneal gap was closed with a running suture. Finally, a “figure-of-eight” stitch was performed to close the fascial defect at the umbilicus.
Variables and outcomes
Data collected included the following: age, gender, hypertension, smoking status, BMI, and ASA score. Preoperative variables such as time elapsed from the onset of symptoms to surgery, defect size, type of hernia, the need for enterectomy, operative time, intraoperative complications, and conversion rate were registered. Recovery parameters such as length of hospital stay (LOS), surgical site occurrence (SSO), surgical site infection (SSI), and recurrence rates (RR) were also considered for the analysis. SSO included any wound event such as seroma, hematoma, infected or exposed mesh, enterocutaneous fistula, wound serous or purulent drainage, wound cellulitis, and/or skin necrosis. SSIs were classified according to Centers for Disease Control and Prevention (CDC) criteria into superficial, deep, or organ space. Primary outcomes of interest were as follows: 30-day overall morbidity, SSO, SSI, and mortality rate. Secondary endpoints measures included LOS and RR. Clinical follow-up was performed on postoperative days 10, 30, 180, and then annually. Recurrence was diagnosed by physical examination alone, or with ultrasound or computed tomography (CT) scan in cases of inconclusive clinical assessment.
Patients undergoing EM-LR and EL-LR were propensity score-matched to adjust for baseline differences. The following variables were selected for matching: age, gender, arterial hypertension, diabetes mellitus type 2, smoking status, BMI, ASA score, type of surgery, and defect size. The cases were matched for their propensity scores using a matching ratio of 1:3, nearest-neighbor matching protocol, with a caliper of 0.2. Categorical data were analyzed with the chi-squared test. Continuous variables were compared with Mann–Whitney U test or Student’s t test according to their nonparametric or parametric distribution, respectively. Statistical analysis was performed using R (version 4.0.4) and R Studio (version 1.4.1106) software. A value of P < 0.05 was considered statistically significant in all the analyses.
| Results|| |
During the study period, a total of 1386 patients underwent inguinal hernia repair. The incidence of complicated groin hernia was 2.2% (n = 31), 15 of which (48%) were performed laparoscopically (EM-LR). [Table 1] summarizes preoperative variables after matching. For emergency cases, the median time elapsed between onset of symptoms and the operation was 12 (range: 1–198) h.
Preoperative imaging, mainly ultrasound, was significantly more frequent in EM-LR group (EM-LR: 87% vs. EL-LR: 51%, P < 0.001).
Operative variables are summarized in [Table 2]. No differences were found regarding the operative time (EM-LR: 107 min vs. EL-LR: 117min, P = 0.37) and hernia defect size (EM-LR: 3.6 cm vs. EL-LR: 4.1 cm, P = 0.48). Although small bowel obstruction was observed in all emergent cases, no patients required enterectomy. No significant difference was observed between EM-LR and EL-LR regarding the type of hernia. No intraoperative complications or conversion to open surgery was registered. There was higher proportion of procedures performed by a specialist in the emergency group (EM-LR: 87% vs. EL-LR: 24%, P < 0.001).
Mean LOS was longer in the EM-LR group (EM-LR: 3.1 day vs. EL-LR: 0.3 day, P < 0.001). Overall 30-day morbidity was similar between groups (EM-LR: 6.6% vs. EL-LR: 4.4%, P = 0.43). One patient had a seroma in each group and one patient had hematoma in the elective group. No SSI was recorded in either group [Table 3]. There were no readmissions or reoperations. No deaths were registered. After a mean follow-up of 28.2 (6–42) months, no recurrence was found, although one patient developed an umbilical trocar site hernia in EM-LR.
| Discussion|| |
This study shows that the laparoscopic approach is an appropriate alternative for repairing groin hernias in an emergency setting in selected patients. We found that (a) complicated groin hernias are infrequent and (b) EM-LR had similar overall morbidity and recurrence rates than elective repairs.
The incidence of complicated groin hernia is very low, ranging from 0.29% to 2.9%. However, it is a life-threatening entity without proper management, as the reported mortality rate reaches up to 9%., In this study, the incidence of complicated groin hernia was 2.2%, and the laparoscopic approach was used in 15 patients (48% of complicated hernias). Most patients were over 70 years old, and although male gender and inguinal hernias were more common, all femoral hernias were found in women. These findings are in concordance with previous studies, and should probably encourage elective hernia repair in the elderly. Overall, conservative management of inguinal hernia in this population might be hazardous because the risk of complications increases overtime.,
Since its introduction, laparoscopic techniques to repair inguinal hernias have gained wide acceptance and have become the treatment of choice in centers of reference. [2,18] Despite the well-known benefits of laparoscopic approaches, TAPP and the totally extraperitoneal (TEP) techniques are used in less than 15% of patients undergoing elective repair.,, Limited institution’s resource, longer learning curve than the open approach, and lack of training are significant challenges for embracing laparoscopy in hernia surgery. Facing a difficult scenario like a complicated inguinal hernia might further discourage the use of laparoscopy, unless a specialized surgeon is available. Accordingly, in a recent 10-year retrospective analysis, the laparoscopic approach for complicated inguinal hernias was used only in 1.2% (3/257) of the emergent cases.
Historically, the open inguinal approach is used in most patients at the time of repairing a complicated hernia. However, reduction and adequate evaluation of hernia content are keys to decide if a resection is required. Opposite to the open repair, laparoscopy allows a thorough exploration of the entire abdominal cavity and bowel integrity. In concordance, several studies have shown promising results with the laparoscopic approach.,, Previous studies have also shown the feasibility of laparoscopic hernia repair in emergency settings. Leibl et al. performed a 6-year prospective analysis in 194 patients after TAPP repair with encouraging results for the treatment of incarcerated inguinal hernias. Yang et al. compared laparoscopic and open repairs (57 and 131, respectively) in strangulated inguinal hernias and found that the laparoscopic approach was associated with less conversion rate, decreased wound infection, and reduced hospital stay. Recently, two studies reported favorable outcomes after TAPP repair for complicated cases., In our study, a case-control (1:3) comparison of complicated and elective cases after TAPP repair was performed, and no differences were found between groups. In addition, no bowel resection was needed, and a specialized surgeon performed most of the cases. Interestingly, these observations were also observed in previous reports.,, The need for specialized surgeons might explain that less than 500 EM-LR are described in the literature.
The time elapsed from onset of symptoms to surgery may play an important role in determining which approach should be used and also could affect postoperative outcomes. Ishihara et al. were one of the first to publish the use of laparoscopy for complicated hernias and described a series of six patients that were operated within 1 h of the diagnosis, and no bowel resection was reported. Lebeau et al. analyzed 288 patients that underwent surgery for strangulated hernias and found higher morbidity and mortality rates in patients with admission time over 48 h. In our study, the time elapsed between onset of symptoms and surgery was 12 h; no bowel resection was needed and no deaths were registered. Future research is necessary in this topic, since only a few studies have described the time elapsed between symptom onset and surgery.
Regarding LRGHs, both TAPP and TEP techniques are safe, reliable, and cost-effective. Also both have shown comparable results in terms of recurrence and chronic postoperative pain. The choice one approach or another depends on surgeon preferences and training. In this series, TAPP repair was performed for patients underwent emergency groin surgery, as it is the preferred technique in our institution.
Robotic inguinal hernia repair has emerged as an alternative to laparoscopic approach. Despite showing promising outcomes in previous reports, a recent randomized trial showed no clinical benefit with robotics when comparing to laparoscopic approach. In turn, the robotic approach was associated with more operative time and is significantly more expensive than the laparoscopic approach., Therefore, since the robotic approach did not show clear benefits in elective hernia repairs, its potential utility in the emergency setting is uncertain.
The retrospective nature and the small sample size are the main limitation of this study. On the basis of these observations, type II error could have biased the results. However, we believe that our findings reinforce the use of the laparoscopic approach to manage complicated groin hernias, and would help future research.
In conclusion, EM-LR had similar overall morbidity and recurrence rates than elective repairs. Reduced time between symptom onset and surgery and availability of a specialized surgeon might help obtaining favorable postoperative outcomes. Prompt surgical exploration and training in laparoscopic hernia surgery should be further encouraged.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Criteria for inclusion in the authors’/contributors’ list
The ICMJE (International Committee of Medical Journal Editors) authorship criteria were used to define authorship.
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[Table 1], [Table 2], [Table 3]