Totally extraperitoneal versus transabdominal preperitoneal approach: A comparative study between the two laparoscopic procedures

Mohammad Aslam; Junaid Alam; Manisha Singh; Maikal Kujur

doi:10.4103/sjl.sjl_4_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 7 | Issue : 1 | Page : 12-17

Totally extraperitoneal versus transabdominal preperitoneal approach: A comparative study between the two laparoscopic procedures

Mohammad Aslam¹, Junaid Alam², Manisha Singh¹, Maikal Kujur¹
¹ Department of Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
² Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

Date of Submission	16-Jun-2021
Date of Acceptance	03-Aug-2021
Date of Web Publication	16-Nov-2022

Correspondence Address:
Dr. Maikal Kujur
B3, Alkareem Plaza, Medical Road, Aligarh- 202 002, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/sjl.sjl_4_21

Abstract

Background: Groin hernia surgery is one of the most common procedures performed by surgeons worldwide. With the advent of minimal access surgery, the procedure for repair is now done either by transabdominal preperitoneal approach Transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approach. The advantage of one procedure over the other is still controversial.
Objectives: This prospective study was conducted to find out the intraoperative and postoperative outcomes of TEP and TAPP for inguinal hernia repair in terms of operative time, intraoperative complications, conversion to open, visual analog scale (VAS) score, postoperative complications, length of hospital stay, and recurrence of hernia and chronic pain.
Materials and Methods: A total of 88 patients of inguinal hernia enrolled prospectively between November 2017 and November 2019 and patients aged 18 years and above admitted in Jawaharlal Nehru Medical College and Hospital were included in this study. Forty-four patients were included in TEP group, while 44 patients were allocated to TAPP group.
Results: The statistical analysis was done using Chi-square test and unpaired t-test, respectively. The mean operative time in TEP was 91.14 ± 11.14 min and in TAPP repair was 103.16 ± 6.79 min, which was found to be significantly significant. The mean pain score on VAS score on postoperative day 1 was 5.70 ± 0.95 in laparoscopic TEP group and 5.86 ± 0.97 in laparoscopic TAPP group. The mean pain score on VAS score on postoperative day 2 was 3 ± 1.27 in laparoscopic TEP group and 2.95 ± 1.29 in laparoscopic TAPP group. Similarly, the mean pain score on VAS scale on postoperative day 7 was 0.863 ± 1.26 in laparoscopic TEP group and 0.659 ± 1.21 in laparoscopic TAPP group. No significant difference was observed in VAS between TEP and TAPP groups during follow-up. Both TEP and TAPP mesh techniques were comparable in terms of the intraoperative complications and postoperative complications (seroma [during hospital stay, after 1 week of discharge, after 1 month of follow-up]; hematoma [during hospital stay, after 1 week of discharge]; wound infection) and in conversion to open and length of hospital stay. The difference in mean cost of surgery was found to be statistically significant.
Conclusion: Although the mean operative time and cost of surgery were significantly more in TAPP than in TEP group, no significant difference could be found between the intraoperative and postoperative complication rates, conversion to open, and length of hospital stay. Recurrence was observed in one case of TEP groups during follow-up. Our study supports the view that both laparoscopic TEP and TAPP mesh repairs of inguinal hernia are safe and efficacious.

Keywords: Totally extraperitoneal, transabdominal preperitoneal approach, visual analog scale score

How to cite this article:
Aslam M, Alam J, Singh M, Kujur M. Totally extraperitoneal versus transabdominal preperitoneal approach: A comparative study between the two laparoscopic procedures. Saudi J Laparosc 2022;7:12-7

How to cite this URL:
Aslam M, Alam J, Singh M, Kujur M. Totally extraperitoneal versus transabdominal preperitoneal approach: A comparative study between the two laparoscopic procedures. Saudi J Laparosc [serial online] 2022 [cited 2023 Jun 9];7:12-7. Available from: https://www.saudijl.org/text.asp?2022/7/1/12/361355

Introduction

A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity. The external abdominal hernia is the most common form, the most frequent being the inguinal, femoral, and umbilical, accounting for 75% of cases. The rarer forms constitute 1.5%, excluding incisional hernias.^[1] Ninety percent of the patients are males; the operations most commonly performed in two age ranges are 1–5 years and 55–80 years.^[2] The lifetime risk of development of groin hernias is 27% for men and 3% for women.^[3]+In the early 1990s, Arregui^[4] and Dion^[5] brought a revolution in the concept of the hernia surgery with the introduction of laparoscopic transabdominal preperitoneal (TAPP) repair. Around the same time, the totally extraperitoneal (TEP) repair for hernia surgery was introduced by McKernan and Laws in 1993.^[6]

With the advent of minimal access surgery, hernioplasty is now being done either by TAPP or TEP approach. The advantage of one procedure over the other is still controversial.

This prospective study was conducted to compare the intraoperative and postoperative outcomes of TEP and TAPP for inguinal hernia repair in terms of operative time, intraoperative complications, conversion to open, visual analog scale (VAS) score, postoperative complications, length of hospital stay, time to resume normal work, recurrence of hernia, and development of chronic pain.

Materials and Methods

A total of 88 patients of inguinal hernia enrolled prospectively between November 2017 and November 2018 and patients aged 18 years and above admitted in Jawaharlal Nehru Medical College and Hospital were included in this study. Forty-four patients were included in TEP group while 44 patients were allocated to TAPP group.

Inclusion criteria

Patients diagnosed as having inguinal hernia aged 18 years and above
Patients with unilateral or bilateral inguinal hernia.

Exclusion criteria

Patients not giving consent
Patients who had congenital hernia, recurrent hernia, and cryptorchidism
Patients who already had lower abdominal surgery for some other ailment
People who were not fit for general anesthesia (chronic obstructive pulmonary disease, cardiac causes, etc.).

Detailed history and clinical examination were done in every case before surgery. Investigations before surgery included complete blood count, bleeding time, clotting time, kidney function test, serum electrolyte, blood sugar, X-ray chest, and electrocardiogram.

During intraoperative period, the operative time, intraoperative complications, and conversion to open were noted in both TEP and TAPP groups. Postoperatively, all patients were evaluated for pain (based on VAS which is based on Wong–Baker facial pain rating scale^[7]) in the immediate postoperative period (at 6 h) and also during whole length of the hospital stay and in follow-up after 1 week, 4 weeks, and 3 months of surgery. They were also evaluated for any postoperative complications such as seroma formation, development of hematoma, wound/mesh infection, length of hospital stay, cost of surgery, and recurrence.

Statistical analysis was done using SPSS software version International Business Machines Corporation - Statistical Package for the Social Science (IBM-SPSS) software (Norman H. Nie, Dale H. Bent, C. Hadlai Hull) Windows, Version 24 (Head-quarter: Armonk, New York). Results on continuous measurements were presented with mean and standard deviation (SD), and results on categorical measurements were presented in numbers and percentages. Pearson's Chi-square test and unpaired t-test were used for statistical analysis. A P ≤ 0.05 was deemed statistically significant.

Results

Age distribution

The two groups were comparable with respect to the age and presenting complaints which included pain and groin swelling. Most of the cases in both TEP and TAPP were in the age group of 41–60 years [Table 1] and [Chart 1].

Table 1: Distribution of study group according to age groups

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Operative time

The mean duration of unilateral TEP surgery was 91.14 ± 11.14 min and TAPP was 103 ± 6.79 min. This difference in duration of surgery was statistically significant between the TEP and TAPP groups. The mean duration of surgery by bilateral approach in TEP group was 140 ± 7.21 min and TAPP was 161.5 ± 4.94 min. This difference in duration of surgery was statistically significant between the TEP and TAPP groups [Table 2][Chart 2].

Table 2: Distribution of study group according to duration of surgery in minutes

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Intraoperative complications

In TEP group, 39 (88.6%) patients had no intraoperative complications. In TAPP group, 42 (95.5%) patients did not have any intraoperative complications. Subcutaneous emphysema occurred in 11.36% of patients in the TEP group and 4.5% of patients in the TAPP group. There was no visceral and vascular injury in either of the group. There was no statistically significant difference between the TEP and TAPP groups [Table 3] and [Chart 3].

Table 3: Distribution of study group according to intraoperative complications

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Visual analog scale score

Postoperative day 1

The mean (± SD) VAS score on postoperative day 1 was 5.70 (±0.95) in TEP group and 5.86 (±0.97) in TAPP group. About 36.36% of the TEP patients had a score of 6 and 38.63% in the TAPP group had VAS score of 6. There was no statistically significant difference in VAS pain score on postoperative day 1 between the TEP and TAPP group [Table 4].

Table 4: Distribution of study group according to pain score based on visual analog scale

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Postoperative day 2

The mean VAS score on postoperative day 2 was 3 ± 1.27 in TEP group and 2.95 ± 1.29 in TAPP group. About 9.09% of the patients in TEP group and 11.36 in TAPP group had a score of 5 on postoperative day 2. This difference in pain scores was not statistically significant between the TEP and TAPP groups on postoperative day 2 [Table 4].

Postoperative day 7

The mean (± SD) VAS score on postoperative day 7 was 0.863 (±1.26) in TEP group and 0.659 (±1.21) in TAPP group. This difference in pain scores was not statistically significant between the TEP and TAPP groups on postoperative day 7 [Table 4].

Postoperative at 1 month

All the patients were actively followed up with reminders given to them using short messaging service, mobile phone calls, or regular telephone calls. Patient was followed up for 6 months, was asked about chronic groin pain, and was asked to rate pain on pain rating scale with mean 0.295 for TEP group and 0.272 for TAPP group with P = 0.137, which was statistically nonsignificant. There was no pain in either group after 1 month [Table 4].

Postoperative complications

Seroma formation occurred in 4 (9.09%) patients in TEP group and 3 (6.81%) patients in TAPP group, whereas port site infection was noted in 3 (6.81%) patients in TEP and 4 (9.09%) patients in TAPP group.

In TEP group, 86.36 did not have any postoperative complications. In TAPP group, 86.36% had no postoperative complications. There was no hematoma in either of the group. Scrotal edema was occurred in 11.36% of patients in TEP group and 4.54% of patients in TAPP group. Postoperative ileus was noted in 2.27% in TEP group and 9.09% in TAPP group. There was no statistically significant difference between the TEP and TAPP groups [Table 5].

Table 5: Distribution of study group according to postoperative complications

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Length of hospital stay

The mean (± SD) duration of hospital stay in TEP group was 4.11 (±1.29) days and was 3.81 (±1.10) days in TAPP group. There was no statistically significant difference in mean hospital stay of TEP and TAPP group. 13.63% of patients in TEP group and 9.09% of patients in TAPP group stayed in the hospital for more than 6 days due to pain [Table 6] and [Chart 3].

Table 6: Distribution of study group according to duration of hospital stay in days

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Cost of surgery

Mean (± SD) cost of surgery in the TEP group was 4892.84 international normalized ratio (INR) (±111.70) while in the TAPP group was 5858.08 INR (±125.06). Cost of surgery in the TEP group was less than the cost of surgery in the TAPP group. This difference was found to be statistically significant with P < 0.0001 [Table 7].

Table 7: Distribution of the study group according to cost of surgery in INR

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Recurrence

One patient having bilateral inguinal hernia had recurrence was found after 1 month of surgery.

Discussion

Inguinal hernia surgery is one of the most common elective procedures performed by surgeons. To reduce the intraoperative and postoperative complications, achieving effective repair, lowest possibility of recurrence, rapid return to normal life, cost-effectiveness, and better cosmetic results are the main goals of any hernia surgery. To successfully achieve these goals, the technique of herniorrhaphy has progressed from open to laparoscopic techniques such as TAPP and TEP, performed by experienced minimal access surgeons.^[8]

Most of the studies find that inguinal hernias are more common in the males and middle-aged people.^[8] In our study, all the patients were males in the TAPP group and 43 (97.82) patients were males in the TEP group. Most of the hernias occurred in the age group of 41–60 years. This could further be justified by the fact that males have more tendency to inherent weakness along the inguinal canal due to different anatomical features. Usually, the inguinal canal closes almost completely in the early postnatal period; however, due to some congenital abnormality or due to idiopathic reasons, sometimes, it fails to close completely leaving a weakened area, especially in males. In females, there is less chance that the inguinal canal will not close after birth.^[9]

In earlier studies, it was found that TEP was relatively difficult and usually took longer time to perform than TAPP mainly due to difficulty in recognizing the anatomy.^[10] TAPP requires access to the peritoneal cavity with the placement of a mesh through a peritoneal incision. The mesh is placed in the preperitoneal space covering all potential hernial sites in the inguinal region. The peritoneum is then closed above the mesh.^[11],[12] TEP differs from TAPP in many characteristics, such as the peritoneal cavity is not entered; mesh is used to seal the hernia from outside the peritoneum; it potentially reduces the risk of intra-abdominal organ damage and adhesion formation, which has been linked to TAPP; it saves operative time because the peritoneum is neither opened and nor closed from the inside.

Many studies have estimated duration of operation to be 55–95 min for TEP and 40–70 min for TAPP.^{[13],[14],[15],[16],[17]} The mean operating time in our study in unilateral TEP surgery was 91.14 ± 11.14 min and TAPP was 103 ± 6.79 min. This difference in duration of surgery was statistically significant between the TEP and TAPP groups. The mean duration of surgery by bilateral approach in the TEP group was 140 ± 7.21 min and the TAPP group was 161.5 ± 4.94 min. This difference in duration of surgery was statistically significant between the TEP and TAPP groups.

Many studies have compared the rates of conversion between TAPP and TEP procedures with rates of 0% versus 4%, 0% versus 1.8%, and 5% versus 7%, respectively.^{[18],[19],[20]} However, in the large case series, the conversion rates between TAPP and TEP were very similar at 0.24% and 0.23%, respectively.^[21] No conversion was done in our study.

Most of the previous studies reported similar pain scores in the immediate postoperative period in both the TEP and TAPP procedures.^[9],[22] In our study, there was no statistical significance in pain score between two groups.

In a meta-analysis done by Bracale et al. and Gass et al., there was a significantly longer postoperative hospital stay in the TAPP group as compared to TEP group.^[23],[24] Our study demonstrated that no difference was found in the postoperative length of hospital stay in both TEP and TAPP groups, respectively (P = 0.253).

Recurrence is the important end point of any hernia surgery^[25] and requires proper and complete knowledge of anatomy and better technique of repair to keep the recurrence to a minimum.^[26],[27] Previously reported incidence of recurrence in TEP was approximately 1%–2% and in TAPP was approximately 0%–3%.^[28] In our study, only one hernia repair recurred.

Conclusion

The results of the study have shown that the TEP repair was comparable to the TAPP repair in terms of intraoperative complication, postoperative pain, postoperative complication, and hospital stay. TEP repair takes shorter operative time compared to TAPP repair. TEP repair involves less cost as compared to TAPP repair.

The only limitation in our study was a relatively shorter sample size. In future, the researchers can take up more studies with larger sample size and follow-up period to compare these techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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