The aim of any hernia repair includes decreasing the intraoperative and postoperative complications, achieving effective repair, lowest possible recurrence, rapid return to normal life, cost effectiveness and better cosmetic results. To accomplish all these results, various methods of inguinal hernia repair are in vogue. Open repairs of hernia are being performed worldwide in all general surgery departments. The development of laparoscopic techniques has revolutionized hernia repairs.

Lichtenstein introduced the open mesh repair in 1980 with his “Tension Free” hernioplasty technique. He also advocated the use of polypropylene mesh plugs for the anterior, infra-inguinal repair of femoral hernias.

Arregui and colleagues in 1993 introduced the trans-abdominal preperitoneal prosthetic (TAPP) procedure.[5] In 1993, McKernan and Laws described the totally extraperitoneal prosthetic (TEP) repair. The laparoscopic TEP repair involves creation of a potential space between the peritoneum and the transversalis fascia, also referred to as the preperitoneal space of Bogros.[5] This helps a prosthetic mesh to be placed into the preperitoneal space so that the hernia is repaired posteriorly. [6]

The present study was conducted in the Department of General Surgery, Hamdard Institute of Medical Sciences and Research, New Delhi, 110062, over a time period of 2 years with mean follow up of 6 months.80 patients were operated by open technique and 80 patients by laparoscopic TEP technique.

Interestingly, we didn’t have any female patient in our study and all of them were men in the age group of 20 to 60 years and above, with a mean age of 49 years in group A and 53 years in group B. The mean age in a study conducted by Malik AM et al was 40.27 years with a standard deviation of 9.724 and a range of 38 (20-58).[7] All patients in our study had unilateral inguinal hernia. In our study, postoperative pain as assessed by individual patient need for analgesia was slightly found to be higher in group B (7.5%) than group A patients (2.5%). This is in accordance with the first randomised controlled trial conducted by Stoker et al. on hernia repair, which compared laparoscopic mesh repair with open repairs. In this study, laparoscopic repair was found to be less painful than open repair.[8] Since then, several randomised controlled studies and systematic reviews have largely confirmed these results. [9, 10] Postoperative urinary retention was found to be lower in group A (2.5%) compared to group B (7.5%). Jain et al. in their study laparoscopic versus open inguinal hernia repair reported a rate of urinary retention to the tune of 6.3%. In open group they reported the rate of 1.7%.[11]Vidovec et al reported a higher rate of urinary retention after TEP which was successfully managed by catheter drainage.[13] Shah et al, in their study reported a rate of 5% in laparoscopic group and 10% in open hernia group.[13] In our study, we found a higher rate of urinary retention in open hernia group probably because of most of these patients were in older age group and most of the cases in open hernia group were done under spinal anaesthesia. We managed this complication by bedside small calibre urinary catheterization under all aseptic conditions and precautions.

In our study 2 patients (2.5%) in group A developed postoperative seroma and same complication was found in 6 patients (7.5%) of group B. This was managed by simple needle aspiration under ultrasound guidance. In 05 patients seroma resolved by conservative management and observation only. Chalkoo M et al, reported seroma formation rate of 4.62% in their study of TEP repair.[14] Furthermore, Zeineldin found seroma in 6% of patients.[15]In a study conducted by Shah et al, they found 0% seroma formation in laparoscopic group and 6.6% seroma formation in open group.[13]

Hernia repair is said to be a clean surgery, therefore most of the centres do not recommend routine antibiotic prophylaxis. However as our centre mostly caters to rural population with poor personal hygiene, we made it a policy in our study to administer a single dose of preoperative prophylactic antibiotic. Our study found a superficial wound infection rate of 1.25% and 5% in groups A and B respectively. This was comparable with the study conducted by Shah et al.[13]

The average hospital stay in our study was 2.5 days in group A and 3 days in open hernia group. The postoperative stay in the hospital was almost comparable in both groups. Cochrane review also reported that the length of hospital stay did not differ between open and laparoscopy groups (WMD-0.04 days, 95% cl -0.08 to 0.00; p=0.05).[16]

Hernia recurrence is one of the most important end result which determines the efficacy of a particular procedure. Our study found a higher recurrence rate in group B than group A. The recurrence rate in group A and group B was 0% and 2.5% respectively. This is comparable with the rates published in literature globally. MRC laparoscopic hernia trial group found 1.9% recurrence rate in laparoscopic group and zero percent recurrence rates in open group at one year.[17]This study involved 928 patients with groin hernias from 26 hospitals in UK and Ireland. Champault et al found recurrence rate of 6% in laparoscopic group versus 3% in open group in a series of 100 patients in a randomized trial.[18] VA trial concluded in 2004 involving 2164 patients in 14 centres in USA measured recurrence of hernia at two years as the primary outcome. Recurrence was found to be 10.1% in the laparoscopic group and 4.1% for open group in the repair of primary inguinal hernias, but rates of recurrence were similar in two groups after repair of recurrent hernias (10% and 14.1% respectively).[19] Return to normal activity was found to be earlier in case of group A (7-10 days) than group B (2 weeks and above).

In our study we found laparoscopic repair to be slightly costlier than open hernia repair. This is probably because of the difference in anaesthesia in laparoscopic and open hernia groups. Further the addition of tackers for mesh fixation added to the cost in laparoscopic repairs, which could be brought down in future by elimination of tackers.

Our study concluded that, laparoscopic TEP repair is a safe and viable option in expert hands for the repair of uncomplicated inguinal hernias. Although slightly costly, laparoscopic hernia repair has comparable results with open hernia repair with fewer general complications. With time, the recurrence rate of TEP is decreasing. The major drawback with laparoscopic TEP repair is its long learning curve, however in experienced hands TEP is better for uncomplicated inguinal hernias in comparison to pain, infection, number of days in hospital, recurrence and return to normal activity. The cost of TEP repair could be brought down by elimination of tackers.