SpringerLink
Log in

Selecting patients during the “learning curve” of endoscopic Totally Extraperitoneal (TEP) hernia repair

  • Original Article
  • Published:
Hernia Aims and scope Submit manuscript

Abstract

Background

Totally Extraperitoneal (TEP) hernia surgery is associated with little postoperative pain and a fast recovery, but is a technically demanding operative procedure. Apart from the surgeon’s expertise, patient characteristics and hernia-related variations may also affect the operative time and outcome.

Methods

Patient-related factors predictive of perioperative complications, conversion to open anterior repair, and operative time were studied in a cohort of consecutive patients undergoing TEP hernia repair from 2005 to 2009.

Results

A total of 3,432 patients underwent TEP. The mean operative time was 26 min (SD ± 10.9), TEP was converted into an open anterior approach in 26 patients (0.8 %), and perioperative complications were observed in 55 (1.6 %) patients. Multivariable regression analysis showed that a history of abdominal surgery (OR 1.76, 95 per cent confidence interval 1.01–3.06; p = 0.05), and the presence of a scrotal (OR 5.31, 1.20–23.43; p = 0.03) or bilateral hernia (OR 2.25, 1.25–4.06; p = 0.01) were independent predictive factors of perioperative complications. Female gender (OR 5.30. 1.52–18.45; p = 0.01), a history of abdominal surgery (OR 3.96, 1.72– 9.12; p = 0.001), and the presence of a scrotal hernia (OR 34.84, 10.42–116.51, p < 0.001) were predictive factors for conversion. A BMI ≥ 25 (effect size (ES) 1.78, 95 % confidence interval 1.09–2.47; p < 0.001) and the presence of a scrotal (ES 5.81, 1.93–9.68; p = 0.003), indirect (ES 2.78, 2.05– 3.50, p < 0.001) or bilateral hernia (ES 10.19, 9.20–11.08; p < 0.001) were associated with a longer operative time.

Conclusion

Certain patient characteristics are, even in experienced TEP surgeons, associated with an increased risk of conversion and complications and a longer operative time. For the surgeon gaining experience with TEP, it seems advisable to select relatively young and slender male patients with a unilateral (non-scrotal) hernia and no previous abdominal surgery to enhance patient safety and ‘surgeon comfort’.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Dulucq JL, Wintringer P, Mahajna A (2009) Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years. Surg Endosc 23:482–486

    Article  PubMed  Google Scholar 

  2. Lau H, Patil NG, Yuen WK (2006) Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males: a randomized trial. Surg Endosc 20:76–81

    Article  PubMed  CAS  Google Scholar 

  3. Eklund A, Rudberg C, Smedberg S, Enander LK, Leijonmarck CE, Osterberg J (2006) Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair. Br J Surg 93:1060–1068

    Article  PubMed  CAS  Google Scholar 

  4. Lal P, Kajla RK, Chander J, Saha R, Ramteke VK (2003) Randomized controlled study of laparoscopic total extraperitoneal versus open Lichtenstein inguinal hernia repair. Surg Endosc 17:850–856

    Article  PubMed  Google Scholar 

  5. Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant AM (2005) Transabdominal pre-peritoneal (TAPP) vs. totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database Syst Rev 1:CD004703

  6. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikinnen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13:343–403

    Article  Google Scholar 

  7. Ou YC, Yang CR, Wang J, Yang CK, Cheng CL, Patel VR, Tewari AK (2010) The learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy by a single surgeon. BJUI Int 2:1–6

    Google Scholar 

  8. Lau H, Patil NG, Yuen WK, Lee F (2002) Learning curve for unilateral endoscopic totally extraperitoneal (TEP) inguinal hernioplasty. Surg Endosc 16:1724–1728

    Article  PubMed  CAS  Google Scholar 

  9. Liem MS, van Steensel CJ, Boelhouwer RU, Weidema WF, Clevers GJ, Meijer WS (1996) The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair. Am J Surg 171:281–285

    Article  PubMed  CAS  Google Scholar 

  10. Aeberhard P, Klaiber C, Meyenberg A, Osterwalder A, Tschudi J (1999) Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC). Surg Endosc 13:1115–1120

    Article  PubMed  CAS  Google Scholar 

  11. Voitk AJ (1998) The learning curve in laparoscopic inguinal hernia repair for the community general surgeon. Can J Surg 41:446–450

    PubMed  CAS  Google Scholar 

  12. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R, Dunlop D, Gibbs J, Reda D, Henderson W, for the Veterans Affairs Cooperative Studies Program (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350:1819–1827

    Article  PubMed  CAS  Google Scholar 

  13. Zendejas B, Onkendi EO, Brahmbhatt RD et al (2011) Long-term outcomes of laparoscopic totally extraperitoneal inguinal hernia repairs performed by supervised surgical trainees. Am J Surg 201(3):379–383

    Article  PubMed  Google Scholar 

  14. Schouten N, Simmermacher RK, van Dalen T, Smakman N, Clevers GJ, Davids PH, Verleisdonk EJ, Burgmans JP (2012) Is there an end of the “learning curve” of endoscopic totally extraperitoneal (TEP) hernia repair? Surg Endosc [Epub ahead of print]

  15. Langeveld HR, van’t Riet M, Weidema WF, Stassen LP, Steyerberg EW, Lange J, Bonjer HJ, Jeekel J (2010) Total extraperitoneal inguinal hernia repair compared with Lichtenstein (the LEVEL-Trial): a randomized controlled trial. Ann Surg 251(5):819–824

    Google Scholar 

  16. Spitz JD, Arregui ME (2000) Sutureless laparoscopic extraperitoneal inguinal herniorrhaphy using reusable instruments: two hundred three repairs without recurrence. Surg Laparosc Endosc Percutan Tech 10:24–29

    PubMed  CAS  Google Scholar 

  17. Koch CA, Greenlee SM, Larson DR et al (2006) Randomized prospective study of totally extraperitoneal inguinal hernia repair: fixation versus no fixation of mesh. JSLS 10:457–460

    PubMed  Google Scholar 

  18. Kark AE, Kurzer M (2008) Groin hernias in women. Hernia 12:267–270

    Article  PubMed  CAS  Google Scholar 

  19. Lau H, Patil NG, Yuen WK (2003) A comparative outcome analysis of bilateral versus unilateral endoscopic extraperitoneal inguinal hernioplasties. J Laparoendosc Adv Surg Tech A 13(3):153–157

    Article  PubMed  Google Scholar 

  20. Gass M, Rosella L, Banz V, Candinas D, Güller U (2012) Bilateral total extraperitoneal inguinal hernia repair (TEP) has outcomes similar to those for unilateral TEP: population-based analysis of prospective data of 6505 patients. Surg Endosc 26:1364–1368

    Article  PubMed  Google Scholar 

  21. Dulucq JL, Wintringer P, Mahajna A (2006) Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or previous lower abdominal surgery. Hernia 9:228–230

    Google Scholar 

  22. Elshof JWM, Keus F, Burgmans JPJ, Clevers GJ, Davids PHP, Van Dalen T (2009) Feasibility of right-sided total extraperitoneal procedure for inguinal hernia repair after appendectomy: a prospective cohort study. Surg Endosc 23(8):1754–1758

    Article  PubMed  CAS  Google Scholar 

  23. Koch A, Edwards A, Haapaniemi S, Nordin P, Kald A (2005) Prospective evaluation of 6895 groin hernia repairs women. Br J Surg 92:1553–1558

    Article  PubMed  CAS  Google Scholar 

  24. Rosemar A, Angeras U, Rosengren A, Nordin P (2010) Effect of body mass index on groin hernia surgery. Ann Surg 252:397–401

    Article  PubMed  Google Scholar 

  25. Lindstrom D, Sadr Azodi O, Belloco R (2007) The effect of tobacco consumption and body mass index on complications and hospital stay after inguinal hernia surgery. Hernia 11:117–123

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

A Research Grant has been assigned to the Diakonessenhuis/Hernia Centre Zeist by Johnson & Johnson to support all research regarding the Totally Extraperitoneal Endoscopic hernia repair.

Author information

Authors and Affiliations

  1. Department of Surgery, Diakonessenhuis, Zeist, Professor Lorentzlaan 76, 3707 HL, Zeist, The Netherlands

    N. Schouten, J. W. M. Elshof, T. van Dalen, G. J. Clevers, P. H. P. Davids, E. J. M. M. Verleisdonk & J. P. J. Burgmans

  2. Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands

    R. K. J. Simmermacher & S. G. A. de Meer

  3. Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands

    P. Westers

Authors
  1. N. Schouten
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. W. M. Elshof
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. K. J. Simmermacher
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. T. van Dalen
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. S. G. A. de Meer
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. G. J. Clevers
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. P. H. P. Davids
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. E. J. M. M. Verleisdonk
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. P. Westers
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. J. P. J. Burgmans
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to N. Schouten.

Additional information

N. Schouten and J. W. M. Elshof contributed equally to this work.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schouten, N., Elshof, J.W.M., Simmermacher, R.K.J. et al. Selecting patients during the “learning curve” of endoscopic Totally Extraperitoneal (TEP) hernia repair. Hernia 17, 737–743 (2013). https://doi.org/10.1007/s10029-012-1006-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10029-012-1006-2

Keywords

Search

Navigation