Totally extraperitoneal laparoscopic hernioplasty: the optimal surgical approach

The total extraperitoneal (TEP) laparoscopic repair of a groin hernia is increasingly being used because of less pain, rapid recovery, and low recurrence rate, but different variants of surgical approaches for TEP are reported by a number of centers and the merits and demerits associated with each approach are not well described. The aim of this study was to compare the clinical outcome of laparoscopic totally extraperitoneal inguinal hernioplasty (TEP) with 4 different variants of surgical approach.

Between August 2004 and March 2008, 99 patients with unilateral inguinal hernia who underwent TEP without mesh fixation through 4 different variants of surgical approach depended on the anatomical positions of abdominal wall were enrolled in this prospective randomized study. The primary endpoints were operative time, incidence of peritoneal tear, and incidence of the arcuate line impeding the position of the mesh. Secondary endpoints were postoperative analgesic requirements and incidence of seroma.

Ninety-nine patients underwent 4 surgical approaches, including the midline approach between the rectus muscle and the posterior rectus sheath (anterior to the posterior rectus sheath, MR) in 25 patients, the midline approach between the peritoneum and the posterior rectus sheath (posterior to the posterior rectus sheath, MP) in 25 patients, the lateral approach between the rectus muscle and the posterior rectus sheath (LR) in 25 patients, and the lateral approach between the peritoneum and the posterior rectus sheath (LP) in 24 patients. The groups were similar in age, weight, body height, and diagnostic categories of hernia. All cases were operated successfully without conversion to open surgery or transabdominal preperitoneal, and followed up for 6 to 43 months with no recurrence. The mean operating time was 55.5 minutes (25 to 130 min) and there was not significant difference between the groups in the operative time. The only type of complication was seroma formation that occurred in 20 patients retrieved without requiring drainage, and there was no significant difference in the incidence of seroma among 4 groups. Only in the MR group and the LR group, the arcuate line in 20 patients impedes the 15 x 10 cm polypropylene mesh positioning. Peritoneal tears were observed without routine closure in 36.7% of patients in the 2 groups of the lateral approach, whereas in only 12% in the 2 groups of the midline approach (P<0.01). Eleven patients required postoperative analgesics, and there was significant difference between the lateral approach groups and the midline approach groups (P<0.05).

TEP is a mature technique and may be safely carried out with fewer complications and lower recurrence rate. Considering the body habitus of each patient and the large dissection surface area resulting in postoperative adhesions and bleeding, according to the principles of "Minimally Invasive Surgery" and the requirement of a maximal cosmetic result, the surgeon should select the midline approach between the peritoneum and the posterior rectus sheath as much as possible.