Comparison of modified tumescent and conventional laparoscopic transabdominal preperitoneal inguinal hernia repair: a retrospective clinical study

Abstract

Objective

Laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair poses certain challenges to less experienced surgeons. This study was performed to compare the clinical outcomes of modified tumescent laparoscopic TAPP (MT-TAPP) inguinal hernia repair versus conventional laparoscopic TAPP (CL-TAPP) inguinal hernia repair.

Methods

We retrospectively analyzed the perioperative data of patients with inguinal hernias who underwent either MT-TAPP repair (n = 57) or CL-TAPP repair (n = 54) at the General Surgery Department of Nanjing Yimin Hospital from November 2019 to June 2023.

Results

The durations of the total operation and the preperitoneal space dissection were shorter in the MT-TAPP than CL-TAPP group. The estimated blood loss volume was lower in the MT-TAPP than CL-TAPP group. The visual analogue scale scores recorded at the 12- and 24-hour postoperative time points showed significantly greater reductions in the MT-TAPP than CL-TAPP group.

Conclusions

Using liquid injection and gauze dissection is both safe and practical. This technique results in a shortened total operation time, less time spent on preperitoneal space dissection, decreased estimated blood loss, and less severe postoperative pain.

Keywords

Liquid injection gauze dissection total operation time estimated blood loss laparoscopy retrospective

Introduction

Laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair has been reported since the 1990s.¹ Laparoscopic TAPP repair offers several advantages over conventional hernia repair, including less pain, less surgical trauma, and faster return to daily activities.^2,3 Patients are encouraged to resume routine activities as soon as they feel comfortable. An additional benefit of the TAPP inguinal hernia repair technique is that it facilitates detection of bilateral hernias. Thorough inspection of the contralateral side is recommended during the TAPP procedure. Laparoendoscopic treatment should be considered for women with groin hernias if appropriate expertise is accessible. The goal of using this approach is to reduce the likelihood of postoperative persistent discomfort and minimize the possibility of missing a femoral hernia.⁴ However, laparoendoscopic repair can be challenging for inexperienced surgeons and trainees because of its steeper learning curve and technical difficulties.^5,6 Approximately 100 cases of supervised laparoendoscopic repair are required to attain outcomes comparable to those achieved with open mesh surgery, such as the Lichtenstein technique.⁴ The procedure requires unique skills and a thorough understanding of the anatomy of the inguinal region. Most recurrences are caused by technical factors, including improper mesh size and fixation, as well as missed hernias.⁷ In China, the number of cases of laparoendoscopic repair has increased, but 3.0% of patients develop recurrence due to prolapsed mesh and inadequate mesh size.⁸ Complications occur in 2.2% of patients, and proper plane dissection is crucial to avoid injuring the vas deferens, spermatic veins, and epigastric vessels.^9–11 Adequate and effective dissection of the preperitoneal space is crucial to prevent recurrence and reduce surgical complications. Liquid injection into the preperitoneal space can facilitate dissection and avoid injuries, making laparoscopic TAPP inguinal hernia repair easier for trainees with limited operational experience. To date, however, little research has been performed to compare this technology with conventional laparoscopic TAPP (CL-TAPP) inguinal hernia repair. In recent years, our team has successfully performed a modified tumescent laparoscopic TAPP (MT-TAPP) inguinal hernia repair using liquid injection and gauze dissection. This study was performed to share our detailed clinical techniques and experience of this technology and to explore the feasibility and advantages of MT-TAPP versus CL-TAPP repair.

Materials and methods

Study population and data collection

We conducted a retrospective analysis of all consecutive patients with inguinal hernias who underwent either MT-TAPP or CL-TAPP repair at the General Surgery Department of Nanjing Yimin Hospital from November 2019 to June 2023. In total, 116 patients were enrolled in the investigation. Five patients were excluded because of postoperative loss to follow-up. As shown in Table 1, the final study population comprised 57 patients in the MT-TAPP group and 54 patients in the CL-TAPP group. The inclusion criteria were an age of 30 to 85 years, the presence of a unilateral indirect inguinal hernia, and an American Society of Anesthesiologists score of ≤3 points. The exclusion criteria were direct inguinal hernias and femoral hernias, incarcerated hernias and strangulated hernias, hernia recurrence after a previous operation, a history of lower abdominal surgery, and serious systemic disease such as heart failure or coagulation dysfunction. None of the patients received antibiotics before the operation.

Table 1.

Basic demographics of patients undergoing MT-TAPP or CL-TAPP repair.

Variable	MT-TAPP repair (n = 57)	CL-TAPP repair (n = 54)	p
Age, years	72.7 ± 9.4	69.2 ± 10.3	0.064
Sex, male/female	30/27	28/26	0.934
BMI, kg/m²	26.0 ± 2.1	25.5 ± 2.7	0.090
Left/right	35/22	30/24	0.532
ASA score			0.836
I	8%	9%
II	26%	26%
III	23%	19%
Comorbidities			0.981
Pulmonary	5%	4%
Renal	2%	3%
Cardiovascular	33%	31%
Diabetes	12%	14%
Liver	4%	6%
Smoking	18%	25%
Hypertension	17%	19%
COPD	6%	7%
Steroid therapy	2%	4%

Data are presented as mean ± standard deviation, number of patients, or percentage of patients.

MT-TAPP, modified tumescent laparoscopic transabdominal preperitoneal; CL-TAPP, conventional laparoscopic transabdominal preperitoneal; BMI, body mass index; ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease.

The study protocol was approved by the Medical Ethics Committee of Nanjing Yimin Hospital, Jiangsu Province, China. Written and verbal informed consent for treatment and publication of this report was obtained from all participants in the study. The verbal consent was audio-recorded during the group activities. The Institutional Review Board of Nanjing Yimin Hospital waived the requirement for us to provide experimental schemes, informed consent forms, and research manuals. The images were fully anonymized before analysis by the authors; the investigators also de-identified all patient information. The reporting of this study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.¹²

Surgical technique

All procedures were carried out with the patient under general anesthesia, inclined at a 30-degree tilt toward the healthy side, and placed in the Trendelenburg position (head inclined downward). The primary surgeon operated from the side opposite the hernia. After establishing carbon dioxide insufflation, a 10-mm trocar for the laparoscope was inserted in the supraumbilical region, and two 5-mm trocars were placed in the left and right rectus abdominis muscle margins at the height of the umbilicus. The pneumoperitoneal pressure was initially set at 12 mmHg.

MT-TAPP repair was performed as follows. The tumescent solution comprised 0.2 mL (0.2 mg) of epinephrine, 30 mL (300 mg) of lidocaine hydrochloride, and 170 mL of physiological saline solution. The peritoneum was gently lifted with a separation forceps, and a metal puncture needle was then inserted into the peritoneum from the trocar on the affected side. Using this device, we performed three punctures in the peritoneum: one in the area between the inferior epigastric artery and the medial umbilical fold, one at the uppermost edge of the internal inguinal ring, and one lateral to the internal inguinal ring (Figure 1). Each time the puncture needle was inserted, the peritoneum was elevated to prevent blood vessel injury. The quantity of injection fluid, which was used to facilitate dissection of the preperitoneal space, was dependent on the extent of the patient’s inguinal region and the degree of porosity. Following injection of the tumescent, the peritoneum around the internal inguinal ring showed signs of swelling. An incision was made in the peritoneum superior to the internal inguinal ring. To provide appropriate tension, the peritoneum was manipulated using separation forceps followed by a gentle blunt separation technique using tiny gauze (Figure 2). The preperitoneal area could be easily distinguished during this part of the procedure. The rest of the operation was consistent with the conventional techniques of TAPP repair. The gauze stripping markings (referring to the identification of anatomical landmarks during dissection of the preperitoneal area using gauze) included the medial pubic symphysis, the lower transverse abdominal aponeurosis, and the lateral anterior superior iliac spine. When the dissection of the preperitoneal area was complete, silk lines were used to measure the distance of the gap. Mesh was then applied to entirely cover the musculopubic foramen. The pneumoperitoneal pressure was minimized after placement of the mesh. Ultimately, closure of the peritoneum was accomplished with the application of 3-0 unidirectional barbed knotless tissue control suture (Stratafix Spiral PGA-PCL; Ethicon, Raritan, NJ, USA).

Figure 1.

Rising of peritoneum secondary to tumescent swelling. (a) Uppermost edge of internal inguinal ring. (b) Lateral to internal inguinal ring and (c) Area between inferior epigastric artery and medial umbilical fold.

Figure 2.

Liquid injection tips and gauze dissection. (a) Before puncture, the peritoneum was gently lifted with separation forceps to avoid damage to the subperitoneal blood vessels. (b) Dissection was performed in the space of Bogros using gauze and (c) Dissection was performed in the space of Retzius using gauze.

CL-TAPP hernia repair was performed using 15- × 15-cm Hermesh 5 (H51515) manufactured by Herniamesh S.r.l. (Turin, Italy).

Definitions

The time of preperitoneal space dissection was defined as the duration from peritoneal incision to complete separation of the preperitoneal space after completion of liquid injection. The time of peritoneal suturing was defined as the duration from placement of the first to last stitch. The time of placement of adequate mesh was operationally defined as the cumulative duration from the first trimming of the mesh to its complete fixation.

Statistical analysis

Statistical analysis was conducted using IBM SPSS 24.0 statistical software (IBM Corp., Armonk, NY, USA). Continuous variables are expressed as mean ± standard deviation and were analyzed using independent-samples t-tests. Categorical variables were compared by the chi-square test or Fisher’s exact test. For nonparametric variables such as the time to first exhaust and hospital stay, we used the Mann–Whitney U test. A p value of <0.05 was considered statistically significant.

Results

Clinical baseline characteristics

This study involved 111 patients (58 men and 53 women). The MT-TAPP group comprised 57 patients, and the CL-TAPP group comprised 54 patients. There were no statistically significant differences in age, sex, body mass index, American Society of Anesthesiologists score, or comorbidities between the two groups of patients (Table 1).

Comparison of intraoperative clinical details between the two groups

The durations of the total operation and the preperitoneal space dissection were shorter in the MT-TAPP than CL-TAPP group (47.5 ± 5.1 vs. 68.3 ± 3.5 minutes, p < 0.0001 and 3.9 ± 0.4 vs. 10.3 ± 1.4 minutes, p < 0.0001). There were no statistically significant differences in the peritoneal suturing time, time of adequate mesh placement, or time of hernia sac dissection. No conversion to traditional surgery occurred in either group. No patients in either group developed any operation-related adverse events, including vascular injury, intestinal injury, bladder injury, vas deferens injury, or spermatic vessel injury. Encouragingly, our investigation revealed that the MT-TAPP group had less estimated blood loss than the CL-TAPP group (15.6 ± 2.1 vs. 20.0 ± 3.2 mL, p < 0.0001) (Table 2). No cardiovascular symptoms, such as hypertension, hypotension, or tachycardia; central nervous system symptoms; or allergic responses were seen throughout the procedure.

Table 2.

Comparison of intraoperative data between the two groups.

Variable	MT-TAPP repair (n = 57)	CL-TAPP repair (n = 54)	p
Total operation time, minutes	47.5 ± 5.1	68.3 ± 3.5	<0.0001
Time of preperitoneal space dissection, minutes	3.9 ± 0.4	10.3 ± 1.4	<0.0001
Time of peritoneal suture, minutes	11.2 ± 0.1	10.9 ± 0.3	0.084
Time of placement of adequate mesh, minutes	13.5 ± 1.1	14.1 ± 1.2	0.067
Time of hernia sac dissection, minutes	15.3 ± 3.1	16.1 ± 2.6	0.059
Conversion	0	0	–
Vascular injury	0	0	–
Intestinal injury	0	0	–
Bladder injury	0	0	–
Vas deferens injury	0	0	–
Spermatic vessels injury	0	0	–
Estimated blood loss, mL	15.6 ± 2.1	20 ± 3.2	<0.0001

Data are presented as mean ± standard deviation or n.

MT-TAPP, modified tumescent laparoscopic transabdominal preperitoneal; CL-TAPP, conventional laparoscopic transabdominal preperitoneal.

Comparison of postoperative outcomes

There were no significant differences in the postoperative hospital stay or time to resuming activity between the two groups. During the 6-month postoperative follow-up, no recurrence was observed in either group. The visual analogue scale scores recorded at the 12- and 24-hour postoperative time points exhibited significant reductions in the MT-TAPP group compared with the CL-TAPP group (2.65 ± 0.48 vs. 4.23 ± 0.86, p < 0.0001 and 2.02 ± 0.23 vs. 3.04 ± 0.91, p < 0.0001). However, there was no significant difference in the visual analogue scale scores between the two groups at 48 hours after surgery. A single case of seroma was observed in the MT-TAPP group and was successfully resolved with the use of puncture. One patient of advanced age in each group developed urinary retention, which was relieved after catheterization, and the patients resumed voluntary urination 2 days later. Three patients in the CL-TAPP group presented differing degrees of chronic pain in the inguinal region, and their symptoms were alleviated by local physiotherapy (Table 3).

Table 3.

Comparison of postoperative data between the two groups.

Variable	MT-TAPP repair (n = 57)	CL-TAPP repair (n = 54)	p
Postoperative hospital stay, hours	90.5 ± 1.3	90.4 ± 0.5	0.612
Time to resuming activity, hours	23.9 ± 1.5	24.3 ± 0.4	0.086
Recurrence	0	0	–
Postoperative VAS score
12 hours after surgery	2.65 ± 0.48	4.23 ± 0.86	<0.0001
24 hours after surgery	2.02 ± 0.23	3.04 ± 0.91	<0.0001
48 hours after surgery	1.02 ± 0.66	1.13 ± 0.32	0.311
Postoperative complications			0.509
Seroma	1	0
Intestinal obstruction	0	0
Urinary retention	1	1
Mesh infection	0	0
Foreign body sensation	0	0
Chronic pain	0	3
Trocar hernia	0	0

Data are presented as mean ± standard deviation or n.

MT-TAPP, modified tumescent laparoscopic transabdominal preperitoneal; CL-TAPP, conventional laparoscopic transabdominal preperitoneal; VAS, visual analogue scale.

Discussion

TAPP repair has been shown to be associated with a reduced incidence of postoperative complications and discomfort compared with open mesh repair.^13–16 The standard approaches for TAPP hernia repair are characterized by their high level of complexity and steep learning curve.¹⁷ Furthermore, hernia recurrence is not infrequent when the procedure is conducted by surgeons lacking the necessary skills and expertise.^18–21 The introduction of fluid into the preperitoneal space serves to enhance the dissection process in TAPP inguinal hernia repair, mitigating the potential for undue harm to adjacent tissues.²² Identification and protection of the vas deferens, spermatic arteries, and epigastric vessels inside the abdominal cavity is technically challenging, particularly for surgeons and surgical trainees who have minimal expertise with TAPP procedures. Lovisetto et al.¹¹ reported a 4.6% incidence of intraoperative complications in the context of TAPP surgery. Notably, about half of these complications (2.2%) were specifically associated with the peritoneal dissection phase of the operation.^23–26

To mitigate the severity of these challenges, we used preperitoneal tumescent local anesthetic immediately before performing TAPP hernia repair. After insufflation had been established, a substantial quantity of tumescent solution was injected into the preperitoneal layer of the inguinal area by a needle catheter that was implanted using trocars. The TAPP procedure was then performed using the standard protocol. During MT-TAPP inguinal hernia repair, we injected a solution consisting of physiological saline solution, lidocaine hydrochloride, and epinephrine into the preperitoneal space. This injection was performed at three specific locations: the region between the inferior epigastric artery and the medial umbilical fold, the uppermost border of the internal inguinal ring, and the lateral aspect of the internal inguinal ring. The liquid-injected area was successfully dissected using gauze. Mizota et al.²⁷ were the first to describe the use of preperitoneal tumescent local anesthesia in 2015. They reported that after trocar placement, 60 mL of 0.3% lidocaine with 1:300,000 dilution of epinephrine was percutaneously injected using a blunt needle.²⁷ We avoid percutaneous puncture, thereby reducing the risk of puncture-related infection and minimizing postoperative pain. Tokumura et al.²⁸ introduced the concept of tumescent TAPP repair. Although their study showed that tumescent TAPP repair makes the conventional TAPP procedure easier and safer, this procedure should be verified by a comparative study with conventional TAPP repair. Therefore, on the basis of their study, we further carried out a comparative study of this procedure. These procedures were not performed simultaneously, and the patients were enrolled from November 2019 to June 2023. The lead surgeon who performed the TAPP procedures had more than 10 years of experience in laparoscopic hernia repair and had successfully completed the learning curve. To minimize selection bias, we alternately assigned the enrolled patients to undergo either MT-TAPP or CL-TAPP.

This study demonstrated that use of the MT-TAPP technique notably reduced both the overall duration of the surgical procedure and the time required for preperitoneal space dissection. Additionally, a substantial decrease in intraoperative estimated blood loss was seen. Previous studies have shown that CL-TAPP hernia surgery is associated with less discomfort and pain in the inguinal area, both during the postoperative period and after discharge, than that resulting from open hernia repair.^29–32 However, McCormack et al.³³ observed that a notable proportion of patients (13.5%) experienced persistent pain after conventional laparoscopic TAPP surgery, indicating the presence of a major long-term complication. In the current study, the incidence of postoperative discomfort was typically low. Only a small minority of patients reported postoperative discomfort, and most experienced resolution of their symptoms within a 3-month period after the surgical procedure; only three patients experienced prolonged chronic pain. The reduced postoperative discomfort was hypothesized to be attributed to the prolonged duration of action of tumescent local anesthetic. Chronic pain was formerly believed to infrequently occur.^34–37 Therefore, the occurrence of postoperative pain after MT-TAPP may be lower than that after CL-TAPP. However, more research is required to confirm this hypothesis. A prospective comparative study might provide evidence of the observed impact.

Conclusion

We have developed an approach known as MT-TAPP inguinal hernia repair. This technique involves the injection of a diluted local anesthetic solution including epinephrine into the inguinal preperitoneal area prior to performing the TAPP procedure and gauze dissection. Positive outcomes were seen in patients who underwent this medical intervention. Therefore, it may be concluded that MT-TAPP surgery provides potential technical and clinical advancements beyond traditional TAPP repair. However, more comparative investigations of this treatment are necessary to further validate the present findings.

Footnotes

Author contributions

Yilong Hu drafted the manuscript. Zhengwei Zhang performed the literature review. Feng Wang performed the procedures. Xiewu Qiu collected and analyzed the data. All authors read and approved the final manuscript.

Data availability statement

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of conflicting interests

The authors declare that there is no competing interest.

Funding

This work was supported by the Jiangsu University Clinical Medical Science and Technology Development Fund [JLY2021198].

ORCID iD

Yilong Hu

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