Laparoscopic TEP (Total Extra-peritoneal) Repair Vs Open PHS (Prolene Hernia System)

In our environment, 10367 (10.41% of all surgeries) hernia repair are performed in one year, of witch 5797 (51.92%) are inguinal hernia repair, of them 2870 (49.51%) are performed laparoscopically and 2927 (50.49%) are performed using different open repair techniques. All consecutive patients that underwent LTEPR repair of inguinal hernia from 2003 to 2007 and open OPHSR inguinal hernia repair from 2008 to 2015, were analyzed. A total of 577 patients were included divided in two groups, the LTEPR group 293 patients and in the OPHSR group 284 patient. The selection of patients for LTEPR was bilateral inguinal hernia or recurrence after open repair, for OPHSR was unilateral inguinal hernia or health condition with preference to regional or local anesthesia. The follow up of all patients was between 18 to 60 months (mean 38.10 month). Setting The LTEPR group was operated by two surgeons with long experience in laparoscopic hernia repair in a public hospital. The selected patients were those with bilateral inguinal hernia or recurrent hernia after open surgery, patients with contraindication for general anesthesia and patients with low midline scar or Pfannenstiel incision were excluded. Patients of the OPHSR group were operated in a private hospital by medical specialists in surgery with experience in repair using PHS; patients under local anesthesia were excluded. Operative technique Pre-op antibiotic shot of 2rd generation cephalosporin was given to all the patients. For LTEPR, under general anesthesia and supine position the plane preperitoneal was developed using a kidney-balloon trocar (Covidien-Medtronic, New Haven, CT, USA) using the 45 degrees scope to evaluate the plane. After developing the preperitoneal space, a structural trocar (Covidien-Medtronic, New Haven, CT, USA) was inserted and the space inflated with gas with low pressure. One working 10-millimeter trocar was inserted in the midline high as possible, if was necessary one more 5-millimeter trocar was inserted under the first one. An atraumatic dissection of the groin was performed, the regional vessels (Corona Mortis, femoral and epigastric) were recognized, the cord was dissected and the peritoneal edge separated and retracted proximally wherever possible. A broad dissection was performed laterally including the Bogros space and superiorly releasing the peritoneum from the anterior abdominal wall. To repair the groin, we use a heavyweight poli-propilene mesh 15X15 centimeters, divides in a piece of 15X5 centimeter inserted under the cord and fixed with helical tackers (Covidien-Medtronic, New Haven, CT, USA) to the ramus pubis and laterally to the transverse abdominal muscle. The second piece of mesh, 10X15 centimeter above the cord overlapping the anterior piece and fixing it to the rectus abdomini and to first mesh inserted. The gas was released and Bupivacaine Hydrochloride 0.5% was injected trough the trocar in the preperitoneal space. For OPHSR, under regional or general anesthesia, in supine position, the groin was incised transversally, the planes were developed and after reduce de sac, the entry to the pre-peritoneal space was gained through the internal ring in indirect hernias, or medial defect in direct hernias. The preperitoneal space was the developed widely in atraumatic way. The posterior patch of the PHS was introduced pre-peritoneally and the onlay patch was fixed with continuous polypropylene sutures or separate stitches. Bupivacaine hydrochloride 0.5% was injected into the tissue around the repair. This study was approved by the institution's ethics committee (Helsinki board). Statistical analysis All of the measured variables and derived parameters were tabulated using descriptive statistics. For the categorical variables, the summary tables provided the sample size, and absolute and relative frequencies. For the continuous variables, the summary tables provided the sample size, arithmetic mean, standard deviation, median, minimum and maximum values, and 95% confidence intervals (CI) for the means of the variables. Analyses were performed using SPSS for Windows version 22.0 (SPSS, Chicago, IL, USA). Differences between two groups were analyzed using the Chi-square test, Fisher's exact test and t-test as adequate. Results were considered statistically significant at p \< 0.05.