COMPARISON OF POSTOPERATIVE

OUTCOME OF LAPAROSCOPIC AND OPEN

INGUINAL HERNIA MESH REPAIR

PRESENTER: Dr. CHALASANI VAISHNAVI

MODERATOR: Dr. A. BHANU PRAKASH,
ASST PROFESSOR
DEPARTMENT OF
GENERAL SURGERY.
AUTHORS:-
• Santosh Duwal

• Kishor Manandhar
CONDUCTED AT

• Department of General Surgery, NAMS, Bir Hospital,

Kathmandu, Nepal.

• Published in International Surgery Journal.

• Duwal S et al. Int Surg J. 2024 Jul;11(7):1081-1085.

INTRODUCTION :-
• Inguinal hernias (IHs) are a common occurrence worldwide and
most performed surgeries as well.

• However, the true incidence of IH is unknown, and nearly

800,000 cases are repaired each year in the USA alone.
INTRODUCTION (contd.):-

• IHs account for 75% of abdominal wall hernias, with a lifetime

risk of 27% in men and 3% in women with cumulative incidence
of 13.9% and 2.1% in male and female respectively requiring
repair in nearly 1 in every 2 men in their lifetime.

• Surgical repair of hernias has been documented as far as back

in an ancient Egyptian and Greek civilizations.
INTRODUCTION (contd.):-
• Bassini (1844-1924) pioneered new method that transformed
inguinal hernia repair into a successful venture with minimal
morbidity.

• The Bassini repair was then modified into McVay and Shouldice
repairs.
INTRODUCTION (contd.):-
• The next major advancement in inguinal hernia repair was
performed by Lichtenstein in 1980, who applied a piece of mesh
to the floor of inguinal canal, allowing a truly tension-free repair.

• Similarly, Ralph Ger described the first potential laparoscopic

inguinal hernia repair in 1982.

• The first total extraperitoneal approach (TEP) to inguinal hernia

repair was first described by McKernon and Laws in 1993.
INTRODUCTION (contd.):-

• As with the transabdominal approach (TAPP), the principles

touted by Rives and Stoppa for open preperitoneal repair of a
large mesh providing coverage over all defects, distributing
intra-abdominal pressure over the large mesh area, and
requiring minimal fixation, were primary principles of the
laparoscopic approach to inguinal hernia repair.
INTRODUCTION (contd.):-
• Since then, there has been many studies and reviews
comparing outcomes in Laparoscopic procedure and open
tension free repairs.

• For inguinal hernia surgery, since other way of IHs repair has its
own advantages and disadvantages, there is still no clear
consensus made regarding superiority of particular procedure.
INTRODUCTION (contd.):-

• Several studies have shown the benefit of the laparoscopic

hernioplasty (LH) over open hernioplasty (OH) in terms of less
postoperative pain and morbidity, wound complications, early
resumption of activity and work and better cosmetic results.
INTRODUCTION (contd.):-

• But the LH repair has some limitation like twice longer operative
time, longer learning curve, higher hospital cost, a potential for
serious life threatening intra-operative complications and a
higher recurrence rate especially immediately in early
postoperative period as compared with open surgery.
INTRODUCTION (contd.):-

• There are advantages and disadvantages in each of these

procedures which should be considered before choosing in
between them.

• Therefore, this study was designed to compare short term

complications in patients undergoing IH surgery by laparoscopic
and open Lichtenstein methods- like hematoma, seroma,
wound infections, cellulitis, scrotal/vulval swelling, pain score
and early return to work and early discharge from hospital.
AIMS AND OBJECTIVES:-

• To Compare the postoperative outcome of laparoscopic and

open inguinal hernia mesh repair.
MATERIALS AND METHODS:

• STUDY DESIGN : Prospective Comparative Observational Study

• STUDY DURATION : August 2020 to January 2021

• STUDY SAMPLE : Total of 56 cases.

• STUDY PLACE : Department of General Surgery, NAMS, Bir

Hospital, Kathmandu, Nepal.
INCLUSION CRITERIA:

• All Elective Inguinal Hernia surgery cases.

• Patients above 16 years of age.

EXCLUSION CRITERIA:

• The patients with emergency IH surgery.

• Associated bowel resection.

• Unfit to any kind of anesthesia.

• Recurrent Inguinal Hernia Repair.

• Bleeding disorder.

• Taking pain medicine prior to surgery for other pathology, under

steroids and previous inguinal area surgery.
METHODS:-

• After ethical clearance from the Institutional Review Board (IRB)

of National Academy of Medical Sciences (NAMS), a
prospective comparative observational study was performed in
Bir Hospital, NAMS, Kathmandu from August 2020 to January
2021.

• Informed consent was taken from the patient.

METHODS:-
• Total 56 patients were included in the study, out of which 28
were allocated in open hernia repair group (OH) and 28 were
allocated in laparoscopic hernia repair group (LH).

• Convenient sampling was done to allocate patients on each

arm.
• Patients under OH group underwent Lichtenstein’s repair under
spinal anesthesia with placement of standard polypropylene
light weight mesh.

• In LH group, patients underwent TAPP repair or TEP repair

under general anesthesia with placement of standard
polypropylene light weight mesh
• Postoperative pains in both groups were assessed with VAS
(Visual analogue score) having a score of 0 to 10 at 0 hour, 12
hours, 24 hours and 48 hours.

• All patients received IV analgesics, i.e IV Ketorolac and IV

Paracetamol on the day of operation, which was converted into
oral medications on the following day.
• During first postoperative day, hematoma, seroma and wound
infection was recorded.

• The duration of hospital stay was recorded and early return to

work was evaluated on subsequent follow up.

• The data obtained were entered using Microsoft Excel and IBM
SPSS statistics 23.

• Statistical analysis was done by using Independent T test, chi-

square (χ2), Fischer exact test.

• P value less than 0.05 termed as statistically significant.

RESULTS
• Out of total 56 patients, 28 patients underwent open hernia
mesh repair and 28 patients underwent laparoscopic mesh
repair.

• Under laparoscopic repair, 6 patients underwent TAPP

procedure and remaining 22 patients underwent TEP procedure

• The mean age of patients in both the groups were comparable.

Table 1: Age distribution of subjects with inguinal
hernia.
LAPAROSCOPIC REPAIR OPEN REPAIR

AGE(YEARS) NUMBER % NUMBER %

16-45 12 42.9 9 32.1

45-60 10 35.7 9 32.1

>60 6 21.4 10 35.7

MEAN 47.36±15.19 53.64±18.78

• The mean hospital stay after surgery was less for LH group
(2.14 vs 2.43 days) compared to open group but was not
statistically significant (p>0.05).
Table 2: Duration of hospital stay.

MEAN DURATION OF STANDARD DEVIATION INDEPENDENT t test

HOSPITAL STAY AFTER (P value )
SURGERY (days)

LAPAROSCOPIC 2.14 0.356 0.286

REPAIR

OPEN REPAIR 2.43 0.573 0.286

• At 12, 24 and 48 hours postoperatively, LH patients described
significantly less pain than the open group (p<0.05).

• Although the VAS pain scores of the LH group were also lower
than the OH group on 0 hour these differences were not
statistically significant
Table 3: Postoperative VAS score

TIME(hours) LAPAROSCOPIC OPEN REPAIR (mean) INDEPENDENT T

REPAIR(mean) TEST (P VALUE)

BASELINE 3.36±1.193 3.68±2.001 0.468

12 3.39±1.166 4.50±1.427 0.002

24 2.71±0.976 3.79±1.031 0.000

48 2.29±0.659 3.04±1.105 0.003

• Two patients in open mesh repair group had wound infection
and four patients in open mesh repair group had seroma
following surgery.

• Five patients in open mesh repair group had scrotal swelling

while one patient in laparoscopic repair had scrotal swelling.

• Even though complications were found more in open repair

group none of the complications were statistically significant
(p>0.05).
Table 4: Postoperative complications.
COMPLICATIONS LAPAROSCOPIC REPAIR OPEN REPAIR FISCHERS EXACT TEST (P
VALUE )

WOUND INFECTION 0 2 0.491

SEROMA 0 4 0.111

SCROTAL 1 5 0.193
SWELLLING
• The study showed that most of the patient returned to normal
work in 13th day in laparoscopic repair group and 21st day on
the open repair group, which is statistically significant (p<0.05).
Table 5: Return to work (in days)

RETURN TO WORK STANDARD DEVIATION INDEPENDENT T TEST ( P

(MEAN ) VALUE )

LAPAROSCOPIC 13.32 2.109 0.000

REPAIR
0.000
OPEN REPAIR 21.21 5.364
DISCUSSION

• In this era of minimally invasive surgery, laparoscopic surgery

has gained popularity in inguinal hernia repair as well.

• There are some distinct advantages of laparoscopic inguinal

hernia repair over conventional open Lichtenstein inguinal
hernia repair.
• The mean hospital stay after surgery was less for LH group
(2.14±0.356 vs 2.43±0.573 days) compared to open group but
was not statistically significant (p>0.05).

• This finding is consistent with review article published by EU

Hernia Trialists Collaboration in 2000 and study done by Mc
Cormack et al.
• Following operation, either open or laparoscopic, patients can
be mobilized early and there is no restriction on diet.

• Patients can get discharged early from hospital if there are no

any complications.

• However, due to other co-morbid condition, or early

complications like seroma and urinary retention, some patients
have prolonged hospital stay.
• Postoperative pain was evaluated using VAS at 0, 12, 24 and
48 hours postoperatively.

• At 12, 24 and 48 hours postoperatively, LH patients

experienced significantly less pain than the open group
(P<0.05).

• Although the visual analogue scale (VAS) pain scores of the LH

group were also lower than the OH group on 0 hour, these
differences were not statistically significant.
• The findings were consistent with other studies by Leigh et al,
Salingam et al, Koju et al.

• However, in 2014 update to the European Hernia Society (EHS)

guidelines based on meta-analysis data there was no difference
in chronic pain after Lichtenstein when compared to TEP hernia
repair.
• In this study they evaluated the immediate postoperative pain
only, and the pain perception can be affected by multiple factors
such as type of surgery, type of anesthesia, intraoperative and
postoperative analgesia.

• Most of the patients in both groups received similar analgesics

in postoperative period, which was given intravenously up to
first postoperative day followed by oral analgesics.
• The open hernioplasty group patients experienced greater
intensity of pain than laparoscopic repair group in this study,
which can be probably explained by extensive dissection
involved in the tissue repairs as well as the size of the incision.

• Surgical complications lead to undesired morbidity and potential

mortality.
• In this study, 2 patients in open mesh repair group had wound
infection, 4 patients in open mesh repair group had seroma
following surgery, 5 patients in open mesh repair group had
scrotal swelling while 1 patient in laparoscopic repair had
scrotal swelling.

• Even though complications were found more in open repair

group none of the complications were statistically significant
(P>0.05)
• Köckerling et al demonstrated a higher postoperative
complication rate following Lichtenstein repair in comparison to
TEP repair in their review of prospectively collected data on
17,388 patients (OR 2.152; CI 1.734–2.672), and a prevalence
rate of 3.2%.

• Shrestha et al found hematoma in 3.1%, Seroma 1.3% and

Scrotal swelling in 3.1% out of 64 IHRs in their study.
• However, in this study there were not any hematoma and
seroma occurrence.

• In the study of Chetan et al presence of surgical site infections

was more in OH group compared to TEP group.

• Another study done by Elwan et al showed 45% cases having

seroma in TAPP group and 5% in conventional group.

• However, in meta-analysis performed in 2014 by Zheng et al,

there was no significant difference in, seroma formation, wound
infections or neuralgia; and no statistically significant difference
in terms of hernia recurrence.
• Surgical complications depend not only upon the technique of
surgery but also the patient profile and co-morbidities.

• Almost all patients were advised routinely for scrotal support in

postoperative period to avoid complications like hematoma and
seroma formation.

• However, some patients developed these complications which

were seen more in OH repair group, and the probable cause
may be due to extensive tissue dissection.
• In this study, there was early return to the work in laparoscopic
repair group than in open repair group, (13.32±2.109 days vs
21.21±5.365 days); which is statistically significant (p<0.05).

• This finding is consistent with the studies done by Stoker et al,

Wilson et al, Chetan et al, Koju et al, in which there were
statistically significant early return in work in laparoscopic repair
group.
• Early return to work shows the quality-of-life following surgery,
and the most essential part of any surgery is to obtain normal
preoperative status.

• Earlier return to work in the LH repair group can be explained

by the facts that these patients experienced less postoperative
pain, earlier mobilization, less post-operative complications,
small wounds; and less extensive tissue dissection; as this
modality of surgery is minimally invasive.
CONCLUSION:-
• This study concludes that laparoscopic inguinal hernioplasty is
better than open hernioplasty in context of less post-operative
pain, early return to work and less risk of wound infection and
other complications.

• However, open surgery has shorter learning curve and can be

performed under local anesthesia.

• Long period of follow up seems essential to assess and

compare the exact efficacy of between the techniques.
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