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Sunday, April 22, 2012

Randomized Clinical Trial of Total Extraperitoneal Inguinal Hernioplasty vs Lichtenstein Repair


A Long-term Follow-up Study
Hasan H. Eker, MDHester R. Langeveld, MDPieter J. Klitsie, MDMartijne van't Riet, MD, PhD;Laurents P. S. Stassen, MD, PhDWibo F. Weidema, MD, PhDEwout W. Steyerberg, PhDJohan F. Lange, MD, PhD;Hendrik J. Bonjer, MD, PhDJohannes Jeekel, MD, PhD 

Arch Surg. 2012;147(3):256-260. doi:10.1001/archsurg.2011.2023

Hypothesis  Mesh repair is generally preferred for surgical correction of inguinal hernia, although the merits of endoscopic techniques over open surgery are still debated. Herein, minimally invasive total extraperitoneal inguinal hernioplasty (TEP) was compared with Lichtenstein repair to determine if one is associated with less postoperative pain, hypoesthesia, and hernia recurrence.

Design  Prospective multicenter randomized clinical trial.

Setting  Academic research.
Patients  Six hundred sixty patients were randomized to TEP or Lichtenstein repair.
Main Outcome Measures  The primary outcome was postoperative pain. Secondary end points were hernia recurrence, operative complications, operating time, length of hospital stay, time to complete recovery, quality of life, chronic pain, and operative costs.
Results  At 5 years after surgery, TEP was associated with less chronic pain (P = .004). Impairment of inguinal sensibility was less frequently seen after TEP vs Lichtenstein repair (1% vs 22%, P < .001). Operative complications were more frequent after TEP vs Lichtenstein repair (6% vs 2%, P < .001), while no difference was noted in length of hospital stay. After TEP, patients had faster time to return to daily activities (P < .002) and less absence from work (P = .001). Although operative costs were higher for TEP, total costs were comparable for the 2 procedures, as were overall hernia recurrences at 5 years after surgery. However, among experienced surgeons, significantly lower hernia recurrence rates were seen after TEP (P < .001).
Conclusions  In the short term, TEP was associated with more operative complications, longer operating time, and higher operative costs; however, total costs were comparable for the 2 procedures. Chronic pain and impairment of inguinal sensibility were more frequent after Lichtenstein repair. Although overall hernia recurrence rates were comparable for both procedures, hernia recurrence rates among experienced surgeons were significantly lower after TEP. Patient satisfaction was also significantly higher after TEP. Therefore, TEP should be recommended in experienced hands.