TEP Medline

TEP medline

Br J Surg. 2001 Jun;88(6):884-6.
Totally extraperitoneal endoscopic repair of recurrent inguinal hernia. van der Hem JA , Hamming JF , Meeuwis JD , Oostvogel HJ . Department of Surgery, St Elisabeth Hospital, Tilburg, The Netherlands. j.vanderhem@heel.azn.nl BACKGROUND: Conventional repair of recurrent inguinal hernia is associated with a re-recurrence rate as high as 35 per cent. Endoscopic mesh repair has promising results regarding both recurrence and complication rates. METHODS: In a retrospective review, the results of endoscopic totally extraperitoneal repair were evaluated in 104 patients with 108 recurrent hernias. Follow-up was at least 1 year. Type of recurrence, time of occurrence after previous repair, duration of surgery, complications, duration of hospital stay and number of re-recurrences were evaluated. RESULTS: Follow-up ranged from 12 to 29 (mean 16) months. Forty-three recurrences were direct, 41 indirect and 15 combined; one was a femoral hernia. Median time to previous operation was 36 months (range 8 days to 42 years). Median duration of surgery was 63 (range 25--160) min. While there were no complications during operation, 12 patients (12 per cent) had a postoperative complication. Two direct re-recurrences (2 per cent) occurred as a result of inadequate positioning of the prosthetic mesh. CONCLUSION: The endoscopic totally extraperitoneal technique is safe and effective for the repair of recurrent inguinal hernia.

Hernia. 2004 May;8(2):113-6. Epub 2003 Nov 21.
Preperitoneal repair for recurrent inguinal hernia: laparoscopic and open approach. Feliu X , Torres G , Vinas X , Martinez- Rodenas F , Fernandez- Sallent E , Pie J . Department of Surgery, Hospital General d'Igualada, Passeig Verdaguer 128, 08700, Barcelona, Spain. 16255xfp@comb.es BACKGROUND: The aim of this study was to investigate the outcome of preperitoneal repair using laparoscopic (TEP) and open (OPM) approach in recurrent inguinal hernia. METHODS: We performed a prospective controlled nonrandomized clinical study in 188 patients with 207 recurrent inguinal hernias over a period of 5 years. TEP repair was employed for 86 repairs, and OPM was used in 121 procedures. The main outcome measurements were: recurrence rate, operating time, hospital stay, and postoperative complications. RESULTS: There were three recurrences (1.7%). Two in the OPM group (1.8%) and one (1.3%) in the TEP group [ P=NS (not significant)]. The TEP procedure was faster than OPM for unilateral repair (40.8 vs 46.3 min) (P<0.001). Postoperative complications were more frequent in the OPM group (23.9%) than the TEP group (13.9%) ( P=NS). Hospital stay was significantly shorter in the TEP group (1.2 vs 3.9 days) (P<0.001). CONCLUSIONS: Preperitoneal approach (open or laparoscopic) seems to be a good option in recurrent inguinal hernia when these procedures are done by experienced surgeons.

J Laparoendosc Adv Surg Tech A. 2004 Dec;14(6):362-7.
Recurrent inguinal hernia: a ten-year review. Feliu X , Jaurrieta E , Vinas X , Macarulla E , Abad JM , Fernandez- Sallent E . Hospital General d'Igualada, Barcelona, Spain. 16255xfp@comb.es BACKGROUND: This study evaluates the results obtained in recurrent inguinal hernia repair over the past ten years in a general hospital using laparoscopic (LAP) and open tension-free mesh (Lichtenstein) procedures. METHODS: A prospective controlled study with 258 recurrent inguinal hernias in 235 patients over a ten-year period. The main outcome measurements were recurrence rate, operating time, hospital stay, postoperative complications, and cost. RESULTS: There were 10 recurrences (4.3%): 7 in the Lichtenstein group (5.7%) and 3 (2.2%) in the LAP group (P = nonsignificant [NS]). There were 15 (12.2%) postoperative complications in the Lichtenstein group and 6 (4.4%) in the LAP group (P =0.04). The operating room costs were higher in the LAP group, but this difference was offset by a significantly shorter hospital stay, shorter operating time, and earlier return to work. CONCLUSION: Laparoscopic repair is an effective option for the treatment of recurrent inguinal hernia. The TEP approach combines the advantages of minimal invasive surgery and those of tension-free mesh repair, reducing operating time, postoperative morbidity, and recurrence rate.

J Laparoendosc Adv Surg Tech A. 1999 Apr;9(2):127-30.
Laparoscopic preperitoneal repair of recurrent inguinal hernias. Sayad P , Ferzli G . Department of Laparoscopic Surgery, Staten Island University Hospital, New York, USA. Repair of recurrent inguinal hernias using the conventional open technique has been associated with high rates of recurrence and complications. Stoppa has reported a low recurrence rate using the open preperitoneal approach. Evolution of laparoscopic techniques has allowed the reproduction of the open preperitoneal repair via an endoscopic totally extraperitoneal (TEP) approach. This study reviewed all the recurrent inguinal hernias repaired laparoscopically and evaluated the complication and recurrence rate. A total of 512 inguinal hernias were treated laparoscopically using the TEP approach. Of these, 75 were recurrent. The ages of the 61 men ranged from 36 to 65 years. There were 41 direct and 34 indirect hernias. Fourteen were bilateral. None of the repairs was converted to an open procedure. The operating time ranged from 20 to 145 min (median 42 min). All patients were discharged home on the same day. There were no deaths. The complications consisted of two instances of urinary retention and one groin collection. Patient follow-up ranged from 6 to 72 (median 40) months, and there have been no recurrences to date. The TEP repair for recurrent inguinal hernias can produce results comparable to the open preperitoneal technique with low morbidity and recurrence rates. PMID: 10235348 [PubMed - indexed for MEDLINE]

Am Surg. 1999 Sep;65(9):839-42; discussion 842-3
Laparoscopic repair of bilateral and recurrent hernias. Frankum CE , Ramshaw BJ , White J , Duncan TD , Wilson RA , Mason EM , Lucas G , Promes J . Atlanta Medical Center, Georgia, USA. The optimal inguinal hernia repair has been controversial for decades. Since the advent of minimally invasive surgery, laparoscopic techniques have added to the controversy. Laparoscopic hernia repair has been advocated by many experts for the repair of bilateral and recurrent inguinal hernias. This study reviews the experience of a single community-based teaching hospital using the total extraperitoneal (TEP)-approach laparoscopic hernia repair for treating patients with bilateral and/or recurrent inguinal hernias. Since the TEP approach was adopted in June 1993, a total of 457 patients were treated for bilateral (322 patients) and/or recurrent (175) inguinal hernias (40 patients had recurrent and bilateral hernias). A total of 779 hernias were repaired with this technique. The average age of this patient group was 47 years, and there were 413 males and 44 females. Operative time averaged 68.3 minutes per patient, and there were 26 (5.7%) minor complications. There were 2 (0.4%) major complications, an enterotomy and a cystotomy, both early in the series and both in patients with previous lower abdominal surgery. There have been no deaths. With an average follow-up of 30 months (range, 1-60 months), there have been three (0.2%) recurrences. These recurrences were due to technical problems (inadequate mesh coverage), and each was repaired with a laparoscopic transabdominal approach or an anterior open approach. The use of the TEP-approach laparoscopic hernia repair is safe and effective in patients with recurrent and/or bilateral inguinal hernias. PMID: 10484086 [PubMed - indexed for MEDLINE]

ANZ J Surg. 2004 Oct;74(10):877-80.
Endoscopic totally extraperitoneal inguinal hernioplasty for recurrence after open repair. Lau H . Department of Surgery, Tung Wah Hospital, University of Hong Kong Medical Centre, Sheung Wan, Hong Kong. lauh@hkucc.hku.hk <lauh@hkucc.hku.hk> BACKGROUND: Whether endoscopic totally extraperitoneal inguinal hernioplasty (TEP) for recurrent inguinal hernia is as safe and efficacious as that for primary inguinal hernia has rarely been examined. The objective of the present study was to compare the early and late outcomes of TEP for primary and recurrent inguinal hernia. The clinical pattern of recurrence after previous open repair of inguinal hernia was also examined. METHODS: Between August 1999 and November 2003, 100 consecutive patients who underwent TEP for recurrent inguinal hernia were recruited. The outcomes of these patients were compared to a randomly selected control group (n = 100) who had TEP for primary inguinal hernia during the same period. All data had been prospectively collected and analysed. RESULTS: Demographic features were comparable between the two groups. The recurrent group had a significantly higher incidence of direct inguinal hernia than the control group (P < 0.001). Comparison of operative duration, postoperative morbidity, pain score, length of hospital stay and time taken to resume normal activities showed no significant differences between the two groups. However, the incidence of peritoneal tear in the recurrent group (46%) was significantly higher than that of the control group (28%) (P < 0.05). With a mean follow-up of 1 year, the incidences of recurrence and chronic groin pain were similar for both groups. CONCLUSION: Early and late outcomes of TEP for recurrent inguinal hernia were equivalent to those for primary inguinal hernia but a higher incidence of peritoneal tear was encountered during TEP for recurrent inguinal hernia. A predominance of direct hernia was observed in the recurrent group.

Am J Surg. 1996 Mar;171(3):366-8. Related Articles, Links
Laparoscopic repair of recurrent inguinal hernias. Sandbichler P , Draxl H , Gstir H , Fuchs H , Furtschegger A , Egender G , Steiner E . Department of Surgery, Hospital Hall/Tirol, Hall, Austria. BACKGROUND: Repair of recurrent inguinal hernias is associated with recurrence rates as high as 30% and complication rates higher than for primary hernias. PATIENTS AND METHODS: In a prospective study, results were evaluated after laparoscopic transabdominal preperitoneal hernia repair in 192 patients with 200 recurrent inguinal hernias. A total of 132 hernia repairs followed one previous repair, 41 followed two repairs, 17 followed three repairs, 6 followed four, 3 followed five, and 1 followed six previous repairs. The surgical technique is described. RESULTS: Follow-up ranged from 9 to 31 months (mean 18.4). Twelve patients (6%) had groin seromas or hematomas; 3 (1.5%) had transient thigh numbness. One patient (0.5%) underwent laparoscopy a second time because of a large hematoma. In 1 patient (0.5%), a staple on the n. cutaneus femoris lateralis was removed laparoscopically. Patients described postoperative pain as being much less severe compared with their previous operation. Of the total group, 76% of patients were able to return to work within 2 weeks of surgery. One recurrence (0.5%) occurred after 6 months because of too small a prosthetic mesh. CONCLUSIONS: This laparoscopic technique can be applied to recurrent hernias, even in difficult cases, with low morbidity rates. Recurrence rates as low as for laparoscopic repair of primary hernias can be expected.

Hernia. 2003 Sep;7(3):125-9. Epub 2003 Apr 11
Management of recurrent inguinal hernias: a prospective study of 163 cases. Barrat C , Surlin V , Bordea A , Champault G . Universite Paris XIII CHU Jean Verdier, Service de Chirurgie Digestive (Pr G Champault), Assistance Publique Hopitaux de Paris, Universite Paris, Av du 14 Juillet, 93140, Bondy, France. There remains debate as to how recurrent inguinal hernias should be managed. This study aimed to establish a management plan for recurrent hernias. From 1991-2000, 163 patients were operated on for recurrent inguinal hernias. The average interval from the initial surgery to recurrence was 46 months (range 10 days-13 years). The initial surgery prior to recurrence was Shouldice and other techniques without mesh in 142 cases, a Stoppa or a Lichtenstein procedure in ten and three cases, respectively, and laparoscopic repair in eight cases. The recurrent hernias were treated with a Shouldice repair in 52 cases (31.9%), the Lichtenstein technique in 48 cases (29.4%), a totally extraperitoneal laparoscopic repair in 40 cases (24.5%), and a Stoppa procedure in 23 (14.1%). The approaches to management evolved with time: the use of prostheses for recurrent hernia repair increased from 10% in 1991 (2/10) to 100% in 2000 (22/22). In contrast, the Shouldice repair decreased from 90% (18/20) in 1991 to 0% (0/22) in 2000. The Lichtenstein technique was first employed in 1993, in patients with a history of a conventional, laparoscopic, or Stoppa repair and has increased to represent 77% of cases (17/22) in 2000. The Stoppa technique has not been used since 1998. The use of a totally extraperitoneal laparoscopic approach went from 11% (2/18) in 1992 (introduction of the technique) to 23% (5/22) in 2000 and is reserved for recurrence after a Lichtenstein procedure or after conventional repair in working and/or physically active patients without any contraindications to general anesthesia. Prosthetic reinforcement has become the norm in the treatment of recurrent hernias. Given a previous conventional repair, the prosthesis can be placed by either an anterior or posterior approach. The approach is dependent on the level of activity and operability of the patient. If the recurrence follows a totally extraperitoneal or a Stoppa procedure, then the Lichtenstein intervention is recommended. A recurrence after a Lichtenstein procedure should be treated by a totally extraperitoneal approach.

Surg Endosc. 1999 Apr;13(4):323-7. Related Articles, Links

Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia? A randomized controlled trial. Beets GL , Dirksen CD , Go PM , Geisler FE , Baeten CG , Kootstra G . Department of Surgery, University Hospital of Maastricht, Post Office Box 5800, 6202 AZ Maastricht, The Netherlands. BACKGROUND: Giant prosthetic reinforcement of the visceral sac (GPRVS), an open preperitoneal mesh repair, is a very effective groin hernia repair. Laparoscopic transabdominal preperitoneal repair (TAPP), based on the same principle, is expected to combine low recurrence rates with minimal postoperation morbidity. METHODS: Seventy-nine patients with 93 recurrent and 15 concomitant primary inguinal hernias were randomized between GPRVS (37 patients) and TAPP (42 patients). Operating time, complications, pain, analgesia use, disability period, and recurrences were recorded. RESULTS: Mean operating time was 56 min with GPRVS versus 79 min with TAPP (p < 0. 001). Most complications were minor, except for a pulmonary embolus and an ileus, both after GPRVS. Patients experienced less pain after a laparoscopic repair. Average disability period was 23 days with GPRVS versus 13 days with TAPP (p = 0.03) for work, and 29 versus 21 days, respectively (p = 0.07) for physical activities. Recurrence rates at a mean follow-up of 34 months were 1 in 52 (1.9%) for GPRVS versus 7 in 56 (12.5%) for TAPP (p = 0.04). Hospital costs in U.S. dollars were comparable, with GPRVS at $1,150 and TAPP at $1,179. CONCLUSIONS: Laparoscopic repair of recurrent inguinal hernia has a lower morbidity than GPRVS. However, laparoscopic repair is a difficult operation, and the potential technical failure rate is higher. With regard to recurrence rates, the open preperitoneal prosthetic mesh repair remains the best repair.

Surg Endosc. 2002 Dec;16(12):1708-12. Epub 2002 Jul 29. Related Articles, Links
Laparoscopic repair of recurrent inguinal hernia. Keidar A , Kanitkar S , Szold A . Endoscopic Surgery Service and the Department of Surgery B, Tel Aviv Sourasky Medical Center and the Sackler School of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel. BACKGROUND: Laparoscopic repair is becoming a popular treatment for recurrent inguinal hernia. The true long-term recurrence of this method is unknown. METHODS: Patients who underwent laparoscopic recurrent inguinal hernia repair at our institution were followed up. Patients were interviewed by phone at least 6 months following surgery and examined by the same surgeon. RESULTS: Between April 1995 and November 2000, 150 laparoscopic repairs of recurrent inguinal hernia were performed in 130 patients. The average operative times were 56 and 68 min for unilateral and bilateral repairs, respectively. There was one conversion to an open procedure. Three patients had intraoperative complications, all identified and repaired laparoscopically. Minor postoperative complications occurred in 24 patients (18.5%), seroma being the most common. There were no injuries to the bowel or major vessels. The average postoperative stay was 1.3 days (range, 0.5-13). Average follow-up was 37 months (range, 7-75). In all, 123 patients (94.6%) were available for interview. Regular activity was resumed by 10.7 days (range, 1-90) and strenuous activity at 24.5 days (range, 1-90). A total of 106 patients with 122 hernias (81.3%) were examined. There were seven recurrent hernias (5.7%). CONCLUSIONS: Laparoscopic repair of recurrent inguinal hernia is effective and has superior long-term results as compared to historical series. If the cost could be reduced, it should probably become the method of choice for the repair of recurrent inguinal hernia.

Hernia. 2005 May;9(2):109-14. Epub 2005 Feb 10. Related Articles, Links
Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review. McCormack K , Wake BL , Fraser C , Vale L , Perez J , Grant A . Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK. k.mccormack@abdn.ac.uk BACKGROUND: The choice of approach to the laparoscopic repair of inguinal hernia is controversial. There is a scarcity of data comparing the laparoscopic transabdominal preperitoneal (TAPP) approach with the laparoscopic totally extraperitoneal (TEP) approach, and questions remain about their relative merits and risks. METHODS: Electronic databases were searched to identify reports of trials comparing laparoscopic TAPP with laparoscopic TEP. In addition, selected conference proceedings were hand-searched, websites consulted, reference lists of all included papers were scanned, and experts contacted for other potentially eligible reports. All published and unpublished randomised controlled trials and quasi-randomised controlled trials comparing laparoscopic TAPP with laparoscopic TEP for inguinal hernia repair were eligible for inclusion. Large non-randomised prospective studies were also eligible for inclusion to provide further comparative evidence of complications and serious adverse events. Two reviewers independently extracted data and assessed study quality. Statistical analyses were performed using the fixed effects model and the results expressed as relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes with 95% confidence intervals (CI). RESULTS: The search identified one RCT which reported no statistically significant difference between TAPP and TEP when considering duration of operation, haematoma, length of stay, time to return to usual activities, and recurrence. The eight non-randomised studies suggest that TAPP is associated with higher rates of port-site hernias and visceral injuries whilst there appear to be more conversions with TEP. Vascular injuries and deep/mesh infections were rare and there was no obvious difference between the groups. No studies reporting economic evidence were identified. CONCLUSIONS: There is insufficient data to allow conclusions to be drawn about the relative effectiveness of TEP compared with TAPP. Efforts should be made to start and complete adequately-powered randomised controlled trials (RCTs), which compare the different methods of laparoscopic repair.

Surg Endosc. 2003 Nov;17(11):1781-3. Epub 2003 Sep 10. Related Articles, Links
Recurrence rate after laparoscopic repair of recurrent inguinal hernias: have we improved? Bingener J , Dorman JP , Valdes G . Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA. Laparoscopic repair of recurrent inguinal hernias is becoming increasingly accepted in surgical practice, using an extraperitoneal or transabdominal approach for the placement of mesh. Previous literature reflects that efforts to perform open repair of recurrent inguinal hernias often result in further recurrences, testicular damage, or nerve injuries. Our study reflects physical examination of 37 patients over 4 years that underwent laparoscopic repair of recurrent inguinal hernia(s). Early and late complications are presented. The re-recurrence rate at this short follow up to 54 months is quite low at 2.5%. The laparoscopic repair of recurrent hernia reflects a very low likelihood of recurrence, low occurrence of testicular damage, and less likelihood of other such complications as nerve or spermatic cord injury (none of these occurred in this study). Seroma was clinically significant in 3 patients and no infections were noted. Our study and ongoing careful follow-up are the subject of this report. Publication Types:
Evaluation Studies

Langenbecks Arch Chir Suppl Kongressbd. 1998;115:1031-3. Related Articles, Links
[Laparoscopic hernia repair of recurrent hernias] [Article in German] Gotzen V , Baca I . Zentrum fur Chirurgie, Zentralkrankenhaus Bremen Ost. Successful treatment of recurrent inguinal hernias is still a problem, in spite of the availability of several different methods. We present our experience with laparoscopic TAP repair, which was performed in 154 patients with 168 recurrent inguinal hernias after traditional anterior repairs. Our results show an acceptable complication rate (5.4%, n = 9) and a low re-recurrence-rate (1.8%, n = 3), combined with the benefit of the minimal access technique, so that this procedure can be recommended in recurrent inguinal hernia repair.

Chirurg. 2001 Dec;72(12):1485-91. Related Articles, Links
[Total endoscopic pre-peritoneal mesh implant in primary or recurrent inguinal hernias] [Article in German] Chiofalo R , Holzinger F , Klaiber C . Chirurgische Abteilung, Spital Aarberg, Schweiz. INTRODUCTION: Since 1994 we perform laparoscopic total extraperitoneal hernia repair (TEP) for primary and recurrent inguinal hernias at our institution. The aim of this study was to investigate and compare the results of TEP in primary inguinal hernias and recurrent inguinal hernias and to determine whether there are differences in patient data, complication rates and outcome between these two groups. METHODS: In a prospective trial 338 patients were analyzed who underwent 500 laparoscopic TEP repairs. In all, 431 TEP repairs were performed for primary inguinal hernias, and 69 for recurrent inguinal hernias. For data acquisition the SALTC study protocol was used. All patients were clinically examined 3 and 12 months after the operation. RESULTS: The mean operation time was 67.3 min for TEP repair of primary hernias and 68.1 min for TEP repair of recurrent hernias, respectively. The conversion rate to an open procedure was 0%. Conversion from TEP into TAPP was required in 0.5% of patients with primary inguinal hernias and 1.4% of patients with recurrent inguinal hernias. As the sole difference between the two groups the intraoperative complication rate could be identified. In the TEP repair group of recurrent inguinal hernias a higher incidence of injury to the peritoneum and a higher occurrence of bleeding from the epigastric vessels was found (P = 0.03). The postoperative complication rate was identical in the two groups, amounting to 5.1% and 5.7%, respectively. No differences were found in the 1 year follow-up between the two groups. The 1-year recurrence rate was 0.5% for primary hernias. However, in the group of recurrent hernias there have been no recurrences to date. CONCLUSIONS: The use of laparoscopic TEP repair has proven to be a safe and effective treatment in patients with primary and recurrent inguinal hernias. Because of scar tissue with possible adhesions a higher intraoperative complication rate was observed in the TEP repair of recurrent hernias than in TEP repair of primary inguinal hernias. However, no single recurrence was observed in the TEP repair group of recurrent hernias. In our opinion TEP is the optimal hernia repair for recurrent and bilateral inguinal hernias.

TEP Medline

by George S. Ferzli

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