1. Laparoscopic (TEP) vs Open Inguinal Hernia Repair: Audit of two year results in Nobles hospital
Marina Yiasemidou, MBBS, MSc
CT1 General Surgery
Audit Lead: Mr I. Iskander

2. Audit -Aim
Compare complications which occurred in Nobles after open mesh and Totally Extraperitoneal Hernia (TEP) Laparoscopic repair with current literature.
Compare hospital stay between lap and open mesh repair in Nobles
Compare recurrence between lap and open mesh repair in Nobles and with current literature

3. Standards

4. Multicenter randomized prospective trial
Sample: 2164 patients
Target Postop f/u - 2 years

7. Methods Retrospective clinical notes inspection Inclusion criteria
>18 y.o
Underwent inguinal hernia repair – TEP or open mesh
Mr Iskander’s team
Duration Jan 2009 – August 2011
Follow up: At least 6 weeks
Statistical Analysis: SPSS Software – Version 18

8. Results
98 patients (Male: 89, Female: 9 Mean age: 59) underwent inguinal hernia repair at Nobles Hospital
61 were laparoscopic, Totally Extra peritoneal approach (Right side: 27, Left: 28, Bilateral: 6)
37 were open mesh repair (Right side: 18, Left side:19)
Open group includes 4 cases of initially laparoscopic converted to open procedures
91 were primary repairs
9 were recurrent
4 were open
5 were laparoscopic
All procedures were performed by or under the supervision of a single consultant surgeon – Mr. Iskander

9. Complication rates – Open Mesh Repair
Number of patients
Groin pain 1
Urinary retention
DVT
Kidney function deterioration
Chest infection
Total 5

10. Complication rate – Laparoscopic (TEP) repair
Number of patients
Rectus sheath haematoma 1
Medial thigh numbness 2
Urinary retention
Groin haematoma
Groin pain
Abscess
Total 9

11. Chi-square test
P=0.932

12. Recurrence Follow up period at least 5 months Laparoscopic Open
2 Recurrences 1 required surgery
Open
1 recurrence
Did not require surgery

13. Hospital stay-Distribution
Open Mesh repair mean: 1.84 Days
TEP repair: 1.34 Days
Same day discharge is considered 1 Day
Normality
Kolmogorov-Smirnov test
P-value: <0.0005

14. Hospital Stay - Distribution

15. Hospital Stay - Comparison
Mann – Whitney test
P= 0.152
No statistically significant difference

16. Satisfaction questionnaire - Overview
Grading system from 0-10
2 patients are deceased for reasons not related to hernia repair
Anonymous responses
Via post in pre paid envelope
Responses: 71 (of 96) – Response rate: 74%
33 Open
38 Laparoscopic

17. Question 1. Were you provided with sufficient information about the Hernia repair?- Grading out of 10
TEP
Open
Difference
8.7
8.66
Essentially zero

18. Q 2. Did you have any pain or discomfort after the surgery?
TEP
Open
Difference
3.5
4.2
0.7 in favour of TEP

19. Q3. How happy where you with the cosmetic results?
TEP
Open
Difference
8.2
7.9
0.3 in favour of TEP

20. Q4. How quickly did you return to your regular daily routine?
TEP
Open
Difference
7.1
5.9
1.2 in favour of TEP

21. Q5.Overall, have you been treated with dignity by the surgical team (Doctors and nurses)?
No need for comparison as it was the same nursing/medical team
Mean Grading for both methods: 9

22. Q6. Overall, how satisfied are you with the procedure you underwent?
TEP
Open
Difference
8.4
8.6
0.2 in favour of Open

23. Type of Anaesthesia - Open

24. Conclusions
Laparoscopic hernia repair performed by a single surgical team has similar complication rates, hospital stay and recurrence rates to the open approach.
This study demonstrates it is safe and feasible to perform TEP inguinal hernia in non specialized centers

25. Questionnaire results
All questions but 1 in favour of TEP
Greatest 2 differences are:
Patients who underwent TEP repair
Had 7% less post operative pain
Returned to daily activities by 12% faster

26. Recommendations Consider anticoagulation therapy for patients:
Pre disposing factors
Overnight stay – Prolonged immobilisation
Assess necessity for prophylactic ABX
Sanabria et al. Prophylactic Antibiotics for Mesh Inguinal Hernioplasty
A Meta-analysis. Ann Surg. 2007 March; 245(3): 392–396.: “50% protective effect of prophylactic antibiotics on decreasing the Surgical Site Infection (SSI) rate in patients submitted to mesh inguinal hernioplasty
Alert medical staff to rare complications: Deterioration of renal function, Chest infection post inguinal hernia repair
Assess necessity for identification of possible sources of infection – Routine dipstick
Consider LA for open – Patient selection for open
Assess long term recurrence – Satisfaction questionnaire
In terms of hospital stay, surgical complications and 6/52 recurrence good practice has been identified, therefore no recommendations are necessary
Re audit when recommendations are implemented

27. Thank you