Improving TEP inguinal hernia repair

Abstract

Inguinal hernias are common phenomena and surgical repair is frequently indicated. Mesh-based techniques are regarded as the gold standard, since they substantially lower the recurrence risk. Endoscopic techniques with use of mesh have become increasingly popular, since they have demonstrated faster recovery, less chronic postoperative pain and higher levels of patient satisfaction. When aiming at improving the TEP procedure, it is important to take the interests of all who are concerned (patients, surgeons, hospitals and society) into account. This thesis addresses several aspects of inguinal hernias and the endoscopic totally extraperitoneal (TEP) inguinal hernia repair method. Inguinal hernias are clinical diagnoses in 95% of cases, and most frequently additional imaging is not required in the diagnostic process. The utilization of ultrasound for diagnosis of inguinal hernias by general practitioners in the Netherlands was specified, and findings of this study demonstrated that relative overuse of groin ultrasound is currently present in primary care. For patients that present with groin pain in combination with a clinically occult groin hernia (not objectified during clinical assessment yet visible on groin ultrasound), the optimal therapeutic strategy has yet to be determined. In this thesis the study protocol of a randomized controlled trial comparing TEP repair to a watchful waiting approach is presented. Athletes suffering from chronic groin pain (inguinal disruption) are a therapeutic challenge. A prospective study performed in athletes that presented with this condition pointed out that TEP hernia repair with reinforcement of the weakened posterior wall is beneficial. Several mesh types have been proposed for endoscopic inguinal hernia repair. Lightweight meshes were developed under the hypothesis they might reduce chronic postoperative pain due to a less severe fibrotic response, however results of a previously performed randomized controlled trial could not confirm this for TEP repair. The long-term five-year analysis of this study demonstrated a higher risk of recurrence development when lightweight mesh was used, therefore this type of mesh is not recommended for TEP inguinal hernia repair. An 11-year analysis of patients reoperated for suspicion of hernia recurrence after TEP repair was conducted. This study pointed out that the majority of recurrences that develop after TEP repair are the same type of hernia that was initially operated, most frequently involving direct hernias. In case of a lipoma mimicking a hernia recurrence, the first repair was that of an indirect hernia in the majority of cases. A prospective study assessing fertility aspects in male patients that underwent bilateral hernia repair was performed. Results of this analysis demonstrated no clinically significant effects on testicular perfusion, testicular volume, serum endocrinological parameters and semen quality in men of fertile age. A cost-analysis of single-visit TEP repair, providing assessment and surgery in one day, compared to the regular routing of TEP hernia repair was performed. Both hospital and societal costs were assessed. The single-visit procedure outpriced the regular procedure in employed, healthy patients, and the greatest cost reduction was found in societal costs.