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Year : 2020  |  Volume : 31  |  Issue : 2  |  Page : 77-81

Retrospective comparison of open- versus single-incision laparoscopic extraperitoneal repair of inguinal hernia procedures: A single-institution experience

1 Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
2 Department of Urology, Kaohsiung Municipal Ta-Tung Hospital; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
3 Department of Urology, Kaohsiung Municipal Ta-Tung Hospital; Graduate Institute of Medicine, College of Medicine; Department of Urology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
4 Department of Urology, Kaohsiung Municipal Ta-Tung Hospital; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Graduate Institute of Medicine; Department of Urology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Date of Submission20-Nov-2019
Date of Decision11-Jan-2020
Date of Acceptance16-Feb-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Ching-Chia Li
No. 100, Shih-Chuan 1st Road, Kaohsiung 80708
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_88_19

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Purpose: In recent years, single-incision laparoscopic surgery (SILS) became more popular worldwide for its safety and feasibility. This study aims to compare the clinical outcomes of open- and single-incision laparoscopic total extraperitoneal (TEP) hernia repair procedures. Materials and Methods: This retrospective study included 498 consecutive patients undergoing open- and single-incision laparoscopic surgeries for inguinal hernia between January 2012 and December 2016 at Kaohsiung Municipal Ta-Tung Hospital. Results: Open inguinal hernia repairs were performed in 436 patients and SILS-TEP repairs in 62 patients. There were no significant differences between the two groups in patients' characteristics except hernia laterality. Mean operative time was significantly longer in the SILS-TEP compared with the open group (108.9 vs. 87.6 min, P = 0.001), but less mean operative duration was observed when surgeons performed bilateral SILS-TEP repairs. Minor amount of analgesic agent usage was noted in the SILS-TEP group. There were no significant differences between the two groups in bleeding volume and postoperative hospital stay and complications. There were 6/453 (1.3%) recurrences in the open group and no recurrences in the SILS-TEP group at a 1-year follow-up. Conclusion: SILS-TEP is both possibly safe and technically feasible and provides less postoperative pain, acceptable operative implications, and better cosmetic outcomes for patients. It also has less possibility of conversion to laparotomy and recurrence rate.

Keywords: Inguinal hernia, single-incision laparoscopic surgery, total extraperitoneal repair

How to cite this article:
Tseng SI, Lee HY, Chueh KS, Tsai CC, Chou YH, Huang CN, Wu WJ, Li CC. Retrospective comparison of open- versus single-incision laparoscopic extraperitoneal repair of inguinal hernia procedures: A single-institution experience. Urol Sci 2020;31:77-81

How to cite this URL:
Tseng SI, Lee HY, Chueh KS, Tsai CC, Chou YH, Huang CN, Wu WJ, Li CC. Retrospective comparison of open- versus single-incision laparoscopic extraperitoneal repair of inguinal hernia procedures: A single-institution experience. Urol Sci [serial online] 2020 [cited 2022 Dec 4];31:77-81. Available from: https://www.e-urol-sci.com/text.asp?2020/31/2/77/283256

  Introduction Top

One of the most frequent operations performed by general surgeons is inguinal hernioplasty, and approximately above 20 million hernias are repaired worldwide annually.[1] The mainstream surgical option for inguinal hernioplasty are, but not limited to, minimally invasive laparoscopic approach and open approach. Since the first description of the three-port approach for laparoscopic hernioplasty in the early 1990s,[2] the technique has become prevalent and gained popularity at many hospitals. Many past studies have proven the feasibility and safety of this procedure.[3] Compared with open surgery, laparoscopic surgery is associated with less postoperative pain, a shorter recovery period, earlier return to normal activities and work, and better cosmetic results.[4],[5] There are two standard methods of laparoscopic inguinal herniorrhaphy: total extraperitoneal repair (TEP) and transabdominal preperitoneal repair. The two techniques basically have no difference in short- and long-term outcomes.[6]

With increasing experience of traditional laparoscopic inguinal herniorrhaphy, the single-incision laparoscopic surgery (SILS) was developed to reduce the number of ports for better cosmetic outcomes and less port-related complications such as incisional hernias and bowel or vascular injuries for the past few years. Since the first report of single-incision laparoscopic TEP Hernia Repair (SILS-TEP),[7] there have been more and more studies in published literature.[8],[9],[10],[11] However, to the best of our knowledge, no report in literature has described the comparative data between open- and SILS-TEP. The aim of this study is to compare the perioperative outcomes and postoperative complications following the two techniques in our institution.

  Materials and Methods Top


We performed a retrospective analysis of 498 patients who underwent an open-herniorrhaphy or SILS-TEP procedure from January 2012 to December 2016 at the Kaohsiung Municipal Ta-Tung Hospital after approval by our Institutional Review Board from the Human Research Ethics Committee (IRB No. KMUHIRB-E(I)-20180308). All patients underwent surgery after providing informed consent and were subject to telephone-based follow-up twice, the first time after six months while the second after one year to record all recurrences. Patients who lost follow-up were excluded from the analyses. Data collected included age, gender, body mass index (BMI), laterality of inguinal hernia, operative time, additional analgesics use for postoperative pain management, length of hospital stay, and intra- and post-operative complications (blood loss, wound infection, dysuria, seroma/hematoma, postsurgery internal bleeding, and recurrence).

Surgical technique

All patients were given prophylactic antibiotics, and surgical procedures were performed under endotracheal general anesthesia. Each patient was placed in the supine position with both arms adducted. The open procedure was carried out according to the Lichtenstein technique.[12] Direct hernia sacs were gently reduced, while indirect sacs were excised. Blunt dissection was made to create surgical space under the external oblique aponeurosis, and we used a 3 × 6 inches monofilament polypropylene mesh (Davol, Bard, USA), trimmed it to fit the inguinal floor, secured it with 2-0 Prolene sutures to the pubic tubercle, conjoint tendon, and inguinal ligament.

The other group, the patients who underwent the SILS-TEP procedure, a 2–2.5-cm transverse incision was made below the umbilicus. The subcutaneous tissue was dissected until the anterior rectus sheath was exposed. Between the anterior and posterior rectus sheath, the preperitoneal space was created by blunt finger dissection and a balloon dissector. A disposable single-port platform (LagisEndosurgical, Taichung, Taiwan) was placed into the space [Figure 1]. A 30° laparoscope (5 mm) was inserted, and the CO2 gas tubing with 15 mmHg pressure was connected to the insufflation port for the maintenance of pneumoperitoneum. The sac was reduced in all cases. However, in some cases, sac reduction was difficult due to adhesions, and the sac was divided just beyond the internal ring. Peritoneal tears were not sutured unless the defect was large. Larger peritoneal tears were fixed using Hem-o-lock clips.
Figure 1: Photograph of disposable single-port platform, which included a plastic wound retractor and a multi-instrument access port

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We used a 3 × 5 inches lightweight mesh (Davol, Bard, USA) to prevent the recurrence of hernia. A lateral slit was made, accounting for a 1/4 section of the mesh [Figure 2]. The mesh was introduced into the preperitoneal space and wrapped around the spermatic cord [Figure 3] from the pubic symphysis to the anterior iliac spine laterally. The mesh was fixed using an absorbable tack fixation device (AbsorbaTack, Medtronic, USA). At least two tacks were used to hold the mesh in position: One was placed at the pubic bone. The other was fixed on the overlapping free edges of the mesh, and the position was at the abdominal wall lateral to the epigastric vessels. If we found the mesh displaced after deflation of the pneumoperitoneum, one or more tacks were applied to immobilize the mesh. The single-skin incision was closed with subcuticular sutures.
Figure 2: A 3 × 5–inch Lightweight mesh (Davol, Bard, USA) was cut with a lateral slit

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Figure 3: The mesh was introduced into the preperitoneal space and wrapped around the spermatic cord. Two tacks were used to affix the mesh

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All laparoscopic and open repairs were performed by five urologists who were well experienced in both techniques. Neither residents nor junior surgeons participated in this study.

Statistical analysis

Statistical analysis was performed using IBM SPSS Statistics Base 22.0 software (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). For the analysis of clinical characteristics and variables between open- and SILS-TEP groups, we used a Student's t-test for continuous variables and Chi-square test for categorical variables. P < 0.05 was considered statistically significant.

  Results Top

Open- and single-incision laparoscopic TEP hernia repair procedures were successfully completed in 498 patients. A total of 436 patients from the open herniorrhaphy group and 62 patients from the SILS-TEP group were studied, and the results were analyzed. Patient demographics were summarized in [Table 1]. The mean age of patients was 60.4 ± 17.6 years in the open group compared with 60.5 ± 12.6 years in the SILS-TEP group. Most patients were male in both groups (open vs. SILS-TEP, 97.7% vs. 98.4%, respectively). The mean BMI was 24.2 ± 3.6 kg/m[2] for the open group and 23.9 ± 2.7 kg/m[2] for the SILS-TEP group. Eight patients who received open surgeries and two patients who received SILS-TEP surgeries had a previous open inguinal hernia repair. We observed a significant difference in hernia laterality, with more bilateral hernias performed (53.2 vs. 3.9%, P < 0.001) in the SILS-TEP group compared with the open group [Table 1].
Table 1: The characteristics of patients receiving inguinal hernia repair

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Perioperative and postoperative outcomes between conventional and SILS-TEP groups were analyzed in [Table 2]. Mean operative time was significantly more in the SILS-TEP compared with the open group (108.9 vs. 87.6 min, P = 0.001), but we observed less mean operative duration when the surgeon performed bilateral SILS-TEP repairs. The additional analgesic agent usage was significantly lesser in the SILS-TEP group (137 vs. 9 patients, P = 0.01). There were no differences in bleeding volume (P = 0.285), postoperative hospital stay (P = 0.154), and postoperative complications (P = 0.623). Twenty-three complications were recorded from 20 patients in the open group, including postoperative seroma/hematoma, surgical wound infection, urinary retention, and recurrent hernia. No severe complications were reported, and almost all cases recovered after conservative management except recurrence. The most common complication in the SILS-TEP group was seroma/hematoma, which subsided over the course of a few weeks. Nevertheless, one patient in the SILS-TEP group experienced massive internal bleeding due to adhesion-related epigastric artery injury that required an immediate surgical intervention for hemostasis.
Table 2: Comparison of perioperative and postoperative outcomes between open and single incision total extraperitoneal hernia repair

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At 1-year follow-up, there were no episodes of recurrence in the SILS-TEP group. At the same follow-up period, six recurrences in the open group occurred, and the patients subsequently underwent successful SILS-TEP or TEP repair.

  Discussion Top

There is still a controversy about the best surgical repair for inguinal hernia. Laparoscopic herniorrhaphy has demonstrated higher complications and recurrence rates than open surgery in earlier reports.[13] However, the present study revealed comparable complication and recurrence rates between laparoscopic and open methods.[4],[5] It indicated that laparoscopic inguinal repair has some advantages compared with open surgery, such as faster recovery, less pain after surgery, earlier return to work, the ability to perform bilateral inguinal repairs in the same time, and in the case with previous inguinal repair history, the prevention of an approaching old scar wound.[14] Since the first SILS-TEP was introduced to inguinal herniorrhaphy by Cugura et al., this technique gained worldwide acceptance in the past few years. Compared with conventional multiple-port laparoscopic surgery, the potential benefits of SILS-TEP identified less incision wound, better cosmesis, reduced pain, improved recovery times, and greater patient satisfaction.[15] Another recent systemic review and meta-analysis showed comparable surgical efficacy and morbidity between SILS-TEP and conventional MP-TEP.[16] Therefore, we can reasonably focus on an issue: SILS-TEP is possibly a feasible alternative method to open surgery. To confirm our hypothesis, we established this study to compare the relationship between SILS-TEP and open method. In our data, the SILS-TEP group had more bilateral hernia repairs than the open group. For an operative time, SILS-TEP procedure is lower in bilateral hernia repairs, while significantly higher in unilateral herniorrhaphy. A prospective clinical study from X. Feliu et al.[17] supports our analytic result. The main explanations are possible as follows: (1) Our patients with bilateral hernias prefer single-incision surgery to open approach due to better cosmesis by a single, nearly scarless wound [Figure 4] and (2) in the SILS-TEP technique, the surgeon created only one access point to perform bilateral repairs, while twice incisions should be done in an open approach.
Figure 4: The postoperative wound of single-incision laparoscopic surgery-total extraperitoneal: A single, nearly scarless wound

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In general, inguinal hernia repair in patients with previous open repair history is more complicated. The laparoscopic method is a better way to perform on such patients because it allows the avoidance of approaching past the wound site. In our clinical observations, the feasibility and acceptable morbidity of laparoscopic surgery applied on recurrent cases as similar results from Wakasugi et al., are also demonstrated.[18] One of the two patients with hernia recurrence in the SILS-TEP group experienced massive internal bleeding during surgery. We found severe fibrotic adhesion between the hernia sac and epigastric vessels, and epigastric artery injury happened while performing sac dissection. Immediate minilaparotomy was performed by extending the port site incision to control bleeding, and direct suturing was completed. There was neither mortality nor other major complications in the SILS-TEP group.

There are seven cases that had postoperative seroma/hematoma formation, but all of them resolved after conservative management. No patients needed a subsequent intervention to treat seroma/hematoma. Eleven cases, which were receiving open hernia repair, suffered from surgical wound infection. All of the wounds were superficial incisional surgical site infection, which had pus formation with or without localized pain and erythema. After opening the wounds, evacuating pus, and cleansing the infected site, the infected wounds spontaneously healed. A patient who developed epididymitis subsided after 1-week therapy of oral antibiotics, and no episode of sepsis was recorded.

We also observed that there are no hernia recurrences in the SILS-TEP group during the follow-up period. In some previous studies, tacker mesh fixation was recommended to prevent recurrences of inguinal hernias.[19] However, some have revealed that tacker fixation may induce chronic groin pain because of insensible nerve injuries.[20] We made modifications to reduce the incidence of recurrence rate and postoperative groin pain. First, we used slit mesh to wrap around the spermatic cord, and the technique was able to reduce the demand for tacks. Second, the absorbable tacks we used to affix the mesh were absorbed by hydrolysis and then metabolized by the body. These methods achieved good clinical results, and even no chronic groin pain was reported in the SILS-TEP group.

To date, more and more studies have revealed that conventional TEP repair had comparable surgical efficacy and recurrence rates with open repair. In addition, quality of life is significantly improved in TEP repair, including postoperative pain and return to functional status.[21] In our study, we reviewed from chart records to mark the patients who had a request for postoperative narcotic treatment. We found significantly less postoperative pain and intravenous analgesics use following SILS-TEP repair. The statistical analysis result was similar to previous literature of conventional TEP versus open repair. However, SILS-TEP surgery had a competitive advantage in cosmetic appearance and less port-related complications and pain.[16]

The difference in hospitalization days was not statistically significant because both techniques produce tolerable pain, and almost all of our patients get much improved after discharging from the hospital the next day. In this study, postoperative complications were rare in SILS-TEP and open groups, and no significant differences were detected between them.

There are several limitations in our study:First, it is a retrospective review study. Second, the follow-up time was performed at two postoperative intervals of 6 months and 1 year, which is certainly a shorter period. Thus, recurrence after 1 year was not be recorded. Third, some demographic and hernia characteristics were not included because they were incompletely recorded.

  Conclusion Top

Our results suggest that SILS-TEP repair is a possibly safe alternative to conventional open surgery and provides better cosmetic and acceptable operative outcomes. However, mesh size, placement, and fixation and clinical experiences are also the key points to make hernia repair successfully without major complications. A patient with previous inguinal hernia repair should not possess any factors of contraindication to undergo SILS-TEP, but the evidence is limited by a small quantity of clinical data. A prospective randomized study is needed to confirm the benefit and long-term results between SILS-TEP repair and open inguinal hernioplasty.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Lal P, Kajla RK, Chander J, Saha R, Ramteke VK. Randomized controlled study of laparoscopic total extraperitoneal versus open Lichtenstein inguinal hernia repair. Surg Endosc 2003;17:850-6.  Back to cited text no. 4
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]

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