Journal club Hernioplasty

1. Journal club presentation
Dr. Raju Khatiwada
1st year resident
General surgery
Moderator: Prof. Dr. Rupesh Mukhia
Date: 30/05/2079

2. Contents
• Introduction
• Objective of the study
• Methodology
• Results
• Discussion
• Limitation
• Conclusion
• Critical appraisal

3. Original article
https://pubmed.ncbi.nlm.nih.gov/34660065/

4. Pyramid of evidence

5. Introduction
• A hernia is a protrusion of a viscus or part of a viscus through the wall of the
cavity in which it normally resides.
• Conditions like coughing, straining, obesity, and intra-abdominal malignancy can
precipitate a hernia.
• Hernias can occur in a number of different anatomical locations, including the
abdominal, femoral, umbilical, and inguinal regions.
• Most common type of hernia is an inguinal hernia, which accounts for about 73%
of all hernia cases.

6. • Many different surgical procedures are performed.
• Most common operations done is mesh repair
• Increased chances of hematoma formation, high incidence of urinary retention,
and increased postoperative pain.
• Minimally invasive procedures like laparoscopic
TAPP (Trans abdominal pre-peritoneal)
Totally extraperitoneal (TEP), and
 Intraperitoneal onlay mesh (IPOM) repair

7. Objective of the study
• To compare Lichtenstein mesh repair with laparoscopic TAPP repair for
postoperative pain and other complications.

8. Methodology
• Data collection:
Randomized clinical trial (RCT)
August 1st 2016, to July 31st 2018 (2 year)
Randomly divided into two equal groups
Consort guidelines followed
Surgical A unit at Khyber Teaching Hospital, Peshawar, Pakistan
Sample size: 100

9. Study protocol:
Not blinded: Patients and health care provider
Blinded: Post-operative PRO (patient reported outcome) assessors
and data analysts
Informed written consent taken
 Only patients with normal labs were included in the study
All patients underwent general anesthesia
Performed by the same group of surgeons having experience of more
than two years

10. Selection criteria
Inclusion criteria:
Patients of 18 to 70 years of age
Having a unilateral inguinal hernia
Patients undergoing elective surgery, and
Those with American Society of Anesthesiologists (ASA) grade I/II

11. Exclusion criteria:
Bilateral inguinal hernia
Obstructed/strangulated hernia
Irreducible hernia
Patients with systemic/local infection
Patients with a previous history of pelvic surgery, and
Contraindications for general anesthesia or laparoscopy.

13. Figure:
Sites for the placement of
laparoscopic ports

14. • visual analog scale (VAS)
0 meaning ‘no pain’ and
10 indicating ‘worst pain’ ever experienced by a patient
• VAS was performed at six and 12 hours after the operation for both groups
• Intravenous (IV) ketorolac (30 mg) and
• Paracetamol (1 gm.) eight hourly up to 24 hours after surgery and then oral
paracetamol (500 mg) 12 hourly
• Follow up: at 1 week after surgery and at 3,6 and 12 month.

15. Data management and analysis
• SPSS version 20 (IBM Corp., Armonk, NY)

16. Data
Quantitative data
- Age
- Postoperative pain
Qualitative data
- Gender
- Hematoma/Seroma
- Scrotal edema
- Urinary retention
- recurrence
Mean and S.D. Frequencies and percentages
Post-stratification was used through the chi-square test, keeping a <0.05 level of
significance to compare the difference between the two groups.

17. Result

18. Pain at 6 hr.
Group-1
(Lichtenstein)
38%(n=19)=moderate
pain
62%(n=31)=severe
pain
Group-2
(TAPP)
34%(n=17)=mild pain
66%(n=33)=moderate
pain
P=<0.05

19. Pain at 12 hr.
Group-1 20%(n=10)=moderate
pain
80%(n=40)=severe pain
Group-2 24%(n=12)=mild pain
76%(n=38)=moderate
pain
P=<0.05

20. Postoperative complication
16 patients in Group-I and three patients in Group-II.
The mean length of hospital stay (LOS) was 2.15 days +/-0.557 S.D.

21. Discussion
• The first laparoscopic repair for inguinal hernia was done in the 1990s
• Laparoscopic hernia repair requires more operating time and depends on the
expertise of the surgeon
• Advantages of reduced postoperative pain, fewer postoperative complications,
reduced hospital stay, and a short period of disability
• All patients included in the study were males
• Zero conversion rate from TAPP to open repair

22. • More postoperative complications (32%) in Group-I compared to Group-II (4%)
• Complications (seroma, hematoma, scrotal edema) are related to inguinal incision
• Recurrence rates after laparoscopic inguinal hernia repair have been reported from
0% to 4%.
• In this study, the recurrence rate was 2% and was similar between both groups
• Chronic pain was significantly higher in Group-I (TAPP: 2%; Lichtenstein repair:
10%)
• LOS was significantly lower in Group- II as compared with Group-I. The
increased LOS in Group-I (2.46 vs. 1.84)

23. Limitation of the study
• Study may not be generalized to other hospital
• Sampling study is not precise

24. Conclusion of the study
Laparoscopic TAPP repair for unilateral inguinal hernia compared to open
Lichtenstein mesh repair has
Less postoperative pain
Fewer postoperative complications and
Shorter hospital stay

25. Critical appraisal

26. Q. Did trial clearly address a clearly focused
issue?
• Authors were explicit and clear on inclusion criteria.
• Participants, Intervention, comparison group and outcomes were clearly defined.

27. Q. Was the assignments of the patients
randomized?
• Computer based simple randomization done.
• Allocation sequences were concealed from researchers and patients.

28. Q. Were all of the patients who entered the trial
properly accounted for at the conclusion?
 Eight patients from Group-I and six patients from Group-II were excluded due to
deranged LFTs
All patients randomised were analysed

29. Q. Were all clinically important outcomes
considered?
Included most common clinical outcomes relevant to both patient and health care
providers.
Tool used for PRO assessment was reliable and externally validated
 Doesn’t specify some postoperative complications related to GA
Not mentioned about of recurrent hernia, size of the hernia
Different space placement of mesh
These studies should not be applied to the women

30. Q. Were the groups similar at the start of trial?
• The baseline characteristics in both groups were quite comparable
• Two hypertensive and one diabetic patient in Group-I, and one hypertensive and
two diabetic patients in Group-II
• All patients included in the study were males
• Demographic characteristics like name, age, sex, address, phone numbers, and
baseline characteristics of all patients were recorded using a standard
questionnaire

31. Q. Aside from the experimental intervention, were
the groups treated equally?
• Since there was no blinding, couldn’t be 100% certain whether participants were
treated equally.

32. Q. Can results be applied to our context?
• Standard guideline recommends tension free mesh repair
• Laparoscopic approach has shown quicker recovery, less pain and better
visualization of the anatomy.
• Controversy exist about the usefulness of laparoscopic repair for the primary
unilateral inguinal hernia

33. Thank You!