|Year : 2018 | Volume
| Issue : 2 | Page : 108-113
Evaluation of short-term outcomes of totally extraperitoneal laparoscopic inguinal hernia repair using a polyester anatomical mesh
Ahmed W Elzayady, Gamal I Moussa, Hamdy S Abdallah, Sherif A Saber
Gastrointestinal and Laparoscopic Surgery Unit, Department of General Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||20-Jul-2017|
|Date of Acceptance||17-Sep-2017|
|Date of Web Publication||31-Oct-2018|
Ahmed W Elzayady
33 Elnagar Street, Mahallet Elborg, El Mahalla Elkobra, Gharbia, 13911
Background Laparoscopic hernia repairs have been gaining worldwide popularity, especially totally extraperitoneal (TEP) repair. The choice of prosthesis became a very important factor as a determinant of the outcome. Polyester anatomical mesh provides enough coverage of hernia defect with many benefits of its polyester-based chemistry.
Aim The aim of the study was to assess the short-term outcomes of laparoscopic TEP repair using a polyester anatomical mesh regarding its safety, efficacy, and impact on patient’s quality of life (QOL).
Patients and methods A prospective assessment of 20 adult patients with uncomplicated inguinal hernia, who underwent laparoscopic TEP repair using polyester anatomical mesh between June 2015 and May 2016 at Tanta University Hospitals. The patient’s QOL was checked preoperatively, at 3 and 6 months postoperatively (PO) using the visual analog scale. The follow-up period was 6 months.
Results The mean age of the patients was 46.18±18.35 years. The mean operative time was 69.7±25.1 min. There were no conversions to other procedures or major complications. The most common operative complication was peritoneal tears in seven (33.3%) hernias. Most common PO complication was small hematoma at the umbilical port in two (10%) patients, which resolved spontaneously. The mean time to return to daily activities was 4.1±0.54 days. There were no recurrences or mesh-related complications. The patient’s QOL significantly improved 6 months PO.
Conclusion Laparoscopic TEP inguinal hernia repair using polyester anatomical mesh without fixation is feasible and safe. It is associated with no chronic pain, no recurrence, minor complications, and better QOL.
Keywords: anatomical mesh, laparoscopic hernia repair, polyester, totally extraperitoneal
|How to cite this article:|
Elzayady AW, Moussa GI, Abdallah HS, Saber SA. Evaluation of short-term outcomes of totally extraperitoneal laparoscopic inguinal hernia repair using a polyester anatomical mesh. Tanta Med J 2018;46:108-13
|How to cite this URL:|
Elzayady AW, Moussa GI, Abdallah HS, Saber SA. Evaluation of short-term outcomes of totally extraperitoneal laparoscopic inguinal hernia repair using a polyester anatomical mesh. Tanta Med J [serial online] 2018 [cited 2018 Nov 18];46:108-13. Available from: http://www.tdj.eg.net/text.asp?2018/46/2/108/244690
| Introduction|| |
Inguinal hernia repair using mesh is one of the most frequently performed operations in general surgery . If the surgeon has technical expertise, laparoscopic hernia repairs result in minimum postoperative (PO) pain, shorter convalescence, and earlier return to work in comparison to conventional hernia repairs ,,. Total extraperitoneal (TEP) repair was described by McKernan and Laws in 1993 .
Compared with conventional polypropylene meshes, polyester anatomical mesh provides larger porosities and increased softness, whereas the handleability of the product remains compatible with laparoscopic placement. The polyester-based chemistry and the rapidly absorbable biological coating increased the hydrophilicity of the mesh, resulting in a fast and intimate tissue ingrowth .
The aim of this study was to assess the short-term outcomes of TEP laparoscopic inguinal hernia repair using a polyester (Parietex) anatomical mesh regarding its safety, efficacy, and impact on patient’s quality of life (QOL).
| Patients and methods|| |
This is a prospective study that was conducted on 20 adult patients with uncomplicated inguinal hernia, who were admitted to the Gastrointestinal and Laparoscopic Surgery Unit, General Surgery Department, Tanta University Hospitals between June 2015 and May 2016. The study protocol was approved by the “Research Ethics Committee” of the Faculty of Medicine, Tanta University. Informed consent was collected from all patients before participation in the study. All adult patients with uncomplicated inguinal hernia are included in this study. Pediatric patients, patients with recurrent hernia after open posterior repair, complicated hernia, and complete indirect hernia (inguinoscrotal), immunocompromised patients, and unfit patients were excluded from this study.
We adopted the technique of laparoscopic TEP repair as described by McKernan and Laws in 1993 . No space makers were used and the initial space was created by telescopic dissection. The mesh used in all patients was Parietex (Covidien, Mansfield, MA, USA) polyester anatomical mesh of 15×10 cm. Nonfixation of the mesh was applied in all cases. Operative findings were recorded including the type of hernia at operation, duration of surgery, inadvertent peritoneal tears (PTs), control of the hernia sac, any operative complications (vessels, visceral, or nerve injuries), conversion, and ease of procedure.
PO pain was assessed using the numerical rating scale, which is an 11-point scale consisting of integers from 0 through 10; 0 representing ‘no pain’ and 10 representing the ‘worst imaginable pain’. Patients select the single number that best represents their pain intensity . Pain was evaluated at 24 h, 10 days PO, and at follow-up appointments. PO morbidities such as seroma, hematoma, wound infection, testicular pain, or any general complications were also noted. The duration of PO hospital stay was noted.
The first follow-up visit was scheduled at 10 days after discharge, then at 1, 3, and 6 months. During these visits any complications as well as any recurrences were recorded. Recurrence was looked for during the follow-up period and confirmed by ultrasound in case of doubt. The time needed to return to normal day-to-day activities and to work was recorded during the follow-up visits. Patient satisfaction was rated as: excellent, good, and fair. All patients were asked about their degree of satisfaction as regards the operation performed at 1 month PO. The patient’s QOL was checked at 3 and 6 months PO. QOL assessment was done using the visual analog scale. The visual analog scale consists of a horizontal line 100 mm in length. Patients are asked to make a mark on the line that best represents the level of QOL that they are experiencing. Higher scores represent better self-perceived health .
Quantitative data were expressed as range, mean, and SD whereas qualitative data were expressed in frequency and percentage. Qualitative data were analyzed using the Monte–Carlo test. Quantitative data were analyzed using the Kruskal–Wallis test. The P value was assumed to be significant at 0.05.
| Results|| |
Between June 2015 and May 2016, 20 patients (all were men) with 21 inguinal hernias underwent laparoscopic TEP repair using polyester anatomical mesh (Parietex). All operating surgeons have good experience with endoscopic surgery. The mean age of the patients was 46.18±18.35 years. Most of the hernias (15, 71.4%) were bubonocele. There were one bilateral and one recurrent hernia after anterior repair ([Table 1]).
All patients were operated under general anesthesia. The mean operative time was 69.7±25.1 min. The method of controlling the hernia sac varied in the studied cases. In 17 (81%) hernias (direct and small indirect sacs), the sacs were completely reduced. In two (9.5%) hernias with long sac and wide neck, the sac was transected at its neck leaving the distal part in situ, with closure of proximal stump using continuous intracorporeal suturing. In two (9.5%) hernias with long sac and narrow neck, the neck was controlled by extracorporeal knot, followed by transaction of the sac distal to the knot. Lipoma of the cord was found in four (19.05%) hernias. Nonfixation of the mesh was applied in all cases.
There were no major operative visceral or vascular complications. Minor operative complications included the following: PTs occurred in seven (33.3%) hernias, one of them was large and managed by continuous intracorporeal suturing, whereas the remaining tears were left without repair as they were small and did not prevent the accomplishment of the procedure. In four (20%) patients with PTs, the working space decreased which required insertion of a Veress needle. Bleeding from a small tributary of inferior epigastric vein occurred in one (4.8%) hernia, which was controlled easily by compression. In one (5%) case, there was oozing that required insertion of a vacuum drain through the suprapubic port for 18 h and removed.
Difficult procedure was noticed only in two (9.52%) hernias. In one case, there were severe adhesions of the hernia sac with the surrounding structures, whereas in the other case, difficulty was due to a decrease in the working space as a result of large PT, which required intracorporeal suturing of the tear in the narrow working space. There were no general complications except hypercapnia in one (5%) case, which required ICU transfer for 12 h and then the patient was discharged with complete resolution. There were no conversions to open surgery or to other procedures ([Table 2]).
PO pain evaluation showed that at the first PO 24 h, the pain score varied between 0 and 5 with a mean of 3±1.21. Seventeen (85%) patients had mild or no pain (score: 0–4) with a mean of 2.78±1.06 and three (15%) patients had moderate pain (score: 5). The pain was experienced at the umbilical port site or in the groin region in all patients except in one who had testicular pain. No neuropathic pain, numbness, or paresthesia were noticed. At PO 10th day, the pain score varied between 0 and 3 with a mean of 0.45±0.89 and 14 (70%) patients were pain free and only six (30%) patients had mild pain (score: 1–3). At 1 month after surgery, only one (5%) patient had mild pain (score: 1), which disappeared in the next follow-up. At third and sixth month PO, all patients were pain free.
The length of hospital stay varied between 1 and 2 days with a mean of 1.4±0.53 days. Hospital stay for most of the patients (n=17, 85%) was 1 day and 2 days in three (15%) patients. PO complications included: surgical emphysema in one (5%) patient, which resolved spontaneously without any complications in 12 h. Small hematoma developed in only two (10%) patients at the umbilical port, which resolved spontaneously without intervention and superficial port site infection occurred in one (5%) case. There was no PO scrotal swelling or recurrence in the studied cases during the follow-up period. All patients were reviewed at the 10th PO day and at first month. Nineteen (95%) patients were reviewed at PO third months and 12 (60%) patients only at PO sixth months with no recorded cases of recurrence among them or mesh-related complications.
Time needed to return to normal daily activities (walking, climbing stairs, bathing, and other activities) varied between 1 and 6 days with a mean of 4.1±0.54 days. Eighty-five percent of the patients resumed normal daily activities within 4 days. The duration of time needed to return to work in 14 (70%) patients who had jobs varied between 5 and 14 days with a mean of 9±1.13 days. At the seventh PO day, nine out of 14 patients (64.3%) returned to work and 12 (92.3%) were able to return to work by PO day 11.
Regarding the degree of satisfaction of their operations, at the first month PO, 12 (60%) patients described it as excellent, seven (35%) patients described it as good, and only one (5%) patient described it as fair. The preoperative QOL score ranged from 60 to 89 with a mean of 79.6±8.41. At 3 months PO, the QOL score of assessed patients (n=18) ranged from 65 to 92 with a mean of 84.65±7.15 and at 6 months PO, the QOL score of the assessed patients (n=13) ranged from 67 to 94 with a mean of 85.77±6.97. When comparing the preoperative with 6 months PO QOL score, it showed that the QOL significantly increased (P=0.001) ([Table 3]).
| Discussion|| |
Laparoscopic TEP repair is gaining wider acceptance than transabdominal preperitoneal because its operative field is totally in the extraperitoneal space and the potential for adhesion formation is minimized . The introduction of biomaterials for inguinal hernia repair has become an integral component of surgery . In fact, 11% of the patients after a mesh-based inguinal hernia repair suffer from chronic pain, more than a quarter of these reports moderate to severe pain . Hence, in international studies it has been mentioned that the choice of the prosthesis in hernia repair is far more important than the technique as a determinant of the outcome .
In fact, there are three big groups of materials concerning nonresorbable meshes: polypropylene, polyester, and polytetrafluoroethylene. Still in the literature there is no consensus as to which material has the best biocompatibility in humans. Polyester is a hydrophilic material as opposed to hydrophobic materials such as polypropylene or polytetrafluoroethylene and thus encourages early biologic fixation and collagen ingrowth into the surrounding tissue. Polyester has also been used as an implanted material in humans for decades in the form of vascular grafts with good safety record .
In this study, there were not any major operative complications (major vessel or visceral injuries). However, PTs were the commonest minor operative complication that occurred in 33.3% of our patients, but it did not prevent the accomplishment of the procedure in any patient. In a randomized multicentric study, a 24% incidence of PTs was found, but loss of pneumoperitoneum occurred only in 7%, which required switching to another technique . In a well-conducted prospective study, Shpitz et al.  concluded that PTs do not have to be routinely closed and the majority of cases may be safely managed without peritoneal closure and with no intra or PO complications that could be attributed to PTs.
In the current study, there were no complications recorded regarding the type of mesh. On the contrary, several benefits of it were experienced by the operating surgeons during the study. First, the anatomical design of the mesh provided good configuration with the inguinal region which facilitated its placement and provided good coverage of the whole myopectineal orifice. Also, its ideal integration with the region decreases the incidence of displacement and makes it unnecessary to use any fixation methods. These results agree with those of other several studies ,.
However, it should be addressed that Parietex anatomical mesh when compared with the conventional most commonly used PPM is relatively expensive.
In a multicenter study in the USA, using polyester anatomical mesh on 495 TEP repairs, Ramshaw et al.  described no complications or infections related to this type of mesh and reported that a repeat laparoscopy several months after left inguinal mesh placement showed the polyester mesh in good position without adhesions or shrinkage of the mesh. In a comparative study in Germany, between polyester mesh and conventional PPM, the authors described that polypropylene meshes, as a hydrophobic material, cause some degree of contraction and scar formation in the long-term follow-up and concluded that PPM meshes give high risk of recurrence, owing to the overall decrease in the size of mesh, as well as an increased subjective foreign body feeling from contracture and scarring. On the contrary, polyester seems not to suffer from these limitations because it is described as hydrophilic ,. In a meta-analysis by Sajid et al. , the authors reported that the incidence of chronic groin pain is significantly reduced after lightweight implantation. These studies add support to the lightweight Parietex anatomical mesh.
Mesh fixation in the laparoscopic hernia repair is currently a debatable issue. Although mesh fixation has been linked to an increased incidence of nerve injury and involves increased PO costs, many surgeons feel that fixation is necessary to reduce the risk of hernia recurrence . A randomized, comparative study of the early outcome of stapled and unstapled techniques of laparoscopic TEP repair showed that unstapled laparoscopic hernia repair scores are equivalent to their stapled counterparts with respect to recurrence and complications. The authors, however, recommend further evaluation in larger study .In the current study, there were no cases of recurrence or chronic pain which is comparable to the data from recent studies that suggest mesh fixation in TEP repairs may be avoided without increasing the risk of hernia recurrence and neuropathic complications ,. Morrison and Jacobs  used polyester anatomical mesh without fixation by additional anchoring devices and has shown excellent long-term results regarding pain and low recurrence rate.
The mean time needed to return to normal daily activities (walking, climbing stairs, bathing, and other activities) was 4.1±0.54 days in the current study. It became clear that endoscopic inguinal hernia repair is associated with shorter recovery periods, earlier return to daily activities and work, and fewer PO complications .
The results of the present study regarding QOL are comparable to that of previous studies. In a prospective, randomized long-term study, Bansal et al.  reported that TEP repair showed significant improvement in QOL from the preoperative period to 3 months PO. Hallén et al.  in a long-term comparative randomized controlled study showed that QOL was better with TEP repairs when compared with open repairs.
| Conclusion|| |
Laparoscopic TEP inguinal hernia repair using the polyester anatomical mesh without fixation is feasible and safe. It is associated with no chronic pain, no recurrence, minor complications, and better QOL.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jain S, Gupta A, Kumar S, Kaza R. Laparoscopic vs. open inguinal hernia repair: a systematic review of literature. Asian J Med Sci 2014; 5:10–14.
Karthikesalingam A, Markar S, Holt P, Praseedom R. Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg 2010; 97:4–11.
Cavazzola L, Rosen M. Laparoscopic versus open inguinal hernia repair. Surg Clin North Am 2013; 93:1269–1279.
Bracale U, Melillo P, Pignata G, Di Salvo E, Rovani M., Merola G et al.
Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with a network meta-analysis. Surg Endosc 2012; 26:3355–3366.
McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993; 7:26–28.
Lepere M, Benchetrit S, Debaert M, Detruit B, Dufilho A, Gaujoux D et al.
A multicentric comparison of transabdominal versus totally extraperitoneal laparoscopic hernia repair using Parietex® meshes. JSLS 2000; 4:147–153.
Ferreira-Valente M, Pais-Ribeiro J, Jensen M. Validity of four pain intensity rating scales. Pain 2011; 152:2399–2404.
Sloan JA, Loprinzi CL, Kuross SA, Miser SA, O’Fallon JR, Mahoney MR et al.
Randomized comparison of four tools measuring overall quality of life in patients with advanced cancer. J Clin Oncol 1998; 16:3662–3673.
Morrison J, Jacobs V. Laparoscopic preperitoneal inguinal hernia repair using preformed polyester mesh without fixation: prospective study with 1-year follow-up results in a rural setting. Surg Laparosc Endosc Percutan Tech 2008; 1833–39
Eriksen JR, Gögenur I, Rosenberg J. Choice of mesh for laparoscopic ventral hernia repair. Hernia 2007; 11:481–492.
Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R. Chronic pain after mesh repair of inguinal hernia: a systematic review. Am J Surg 2007; 194:394–400.
Champault G, Bernard C, Rizk N, Polliand C. Inguinal hernia repair: the choice of prosthesis out-weights that of technique. Hernia 2007; 11:125–128.
Liem MS, van der Graaf Y, van Steensel CJ, Boelhouwer RU, Clevers GJ, Meijier WS et al.
Comparison of conventional anterior surgery and laparoscopic surgery for inguinal hernia repair. N Engl J Med 1997; 336:1541–1547.
Shpitz B, Lansberg L, Bugayev N, Tiomkin V, Klein E. Should peritoneal tears be routinely closed during laparoscopic total extraperitoneal repair of inguinal hernias? A reappraisal. Surg Endosc 2004; 18:1771–1773.
Ramshaw B, Abiad F, Voeller G, Wilson R, Mason E. Polyester (Parietex) mesh for total extraperitoneal laparoscopic inguinal hernia repair. Initial experience in the United States. Surg Endosc 2003; 17:498–501.
Shah BC, Goede MR, Bayer R, Buettner SL, Puyney SJ, McBride CL et al.
Does type of mesh used have an impact on outcomes in laparoscopic inguinal hernia? Am J Surg 2009; 198:759–764.
Langenbach M, Sauerland S. Polypropylene versus polyester mesh for laparoscopic inguinal hernia repair: short-term results of a comparative study. Surg Sci 2013; 4:29–34.
Sajid M, Kalra L, Parampalli U, Sains PS, Baig MK. A systematic review and meta-analysis evaluating the effectiveness of lightweight mesh against heavyweight mesh in influencing the incidence of chronic groin pain following laparoscopic inguinal hernia repair. Am J Surg 2013; 205:726–736.
Khajanchee Y, Urbach D, Swanstrom L, Hansen P. Outcomes of laparoscopic herniorrhaphy without fixation of mesh to the abdominal wall. Surg Endosc 2001; 15:1102–1107.
Parshad R, Kumar R, Priya H, Bal S. A randomized comparison of the early outcome of stapled and unstapled techniques of laparoscopic total extraperitoneal inguinal hernia repair. JSLS 2005; 9:403–407.
Mahon D, Decadt B, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs. open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc 2003; 17:1386–1390.
Miserez M, Peeters E, Aufenacker T, Bouillot JL, Campanelli G, Conze J et al.
Update with level 1 studies of the European Hernia Society guide lines on the treatment of inguinal hernia in adult patients. Hernia 2014; 18:151–163.
Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR. Meta-analysis of randomized clinical trial comparing open and laparoscopic inguinal hernia repair. Br J Surg 2003; 90:1479–1492.
Bansal VK, Misra MC, Babu D, Victor J, Kumar S, Sagar R et al.
A prospective, randomized comparison of long-term outcomes: chronic groin pain and quality of life following totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repair. Surg Endosc 2013; 27:2373–2382.
Hallén M, Bergenfelz A, Westerdahl J. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: long term follow-up of a randomized controlled trial. Surgery 2008; 143:313–317.
[Table 1], [Table 2], [Table 3]