BACKGROUND: The Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) is an open procedure in which the mesh is placed in the preperitoneal space and is therefore associated with less chronic post-operative inguinal pain. TREPP is primarily performed under general or spinal anesthesia, however, it is also possible to perform under sedation and local anesthesia with potentially advantages. This retrospective feasibility pilot study investigates the safety and efficiency of TREPP under local anesthesia in the outpatient clinic in comparison with Lichtenstein.
METHODS: Between 2019 and 2022, all patients who underwent an elective inguinal hernia repair under local anesthesia in the outpatient clinic operation theatre were assessed. 34 patients in the TREPP group and 213 patients in the Lichtenstein group were included. Outcomes were complications, operating time, theatre time, and early inguinal hernia recurrence within 8 weeks and 6 months post-operatively.
RESULTS: No significant differences in complications such as wound infection, hematoma, seroma, urine retention and early recurrence between TREPP and Lichtenstein were found. Post-operative pain at 8 weeks was not significantly higher after Lichtenstein (8.8% vs. 18.8%, P = 0.22). Operating time (21.0 (IQR: 16.0-27.3) minutes vs. 39.0 (IQR: 31.5-45.0) minutes, P < 0.001) and theatre time (37.5 (IQR: 30.8-42.5) minutes vs. 54.0 (IQR: 46.0-62.0) minutes, P < 0.001) was significantly shorter for TREPP.
CONCLUSIONS: This pilot study showed that TREPP appears to be feasible to perform safely under local anesthesia with comparable complication rates and substantially shorter operation time than Lichtenstein. These results justify further research with a larger study population and a longer period of follow up in order to provide firm conclusions.

BACKGROUND: Chronic pain remains prevalent after open inguinal hernia repair and nerve-handling strategies are debated. Some guidelines suggest sparing nerves that are encountered; however, the nerve identification rates are unclear. This study aimed to investigate the nerve identification rates in a register-based nationwide cohort.
METHODS: This study was reported according to the RECORD guideline and used prospective, routinely collected data from the Danish Hernia Database, which was linked with the National Patient Registry. We included patients ≥ 18 years old, undergoing Lichtenstein hernia repair with information on nerve handling of the iliohypogastric and ilioinguinal nerves.
RESULTS: We included 30,911 open hernia repairs performed between 2012 and 2022. The ilioinguinal nerve was identified in 73% of the repairs and the iliohypogastric nerve in 66% of repairs. Both nerves were spared in more than 94% of cases where they were identified. Female patient sex, emergency and recurrence surgery, general anesthesia, medial and saddle hernias, and large defect size all result in lower nerve identification rates for both nerves.
CONCLUSIONS: The Ilioinguinal nerve was recognized in 73% of cases, while the iliohypogastric nerve was recognized in 66% with almost all identified nerves being spared during surgery. Several pre- and intraoperative factors influenced identification rates of the ilioinguinal and iliohypogastric nerve.

Introduction: Bilateral inguinal hernia can be safely repaired simultaneously, open or minimally invasive, in an elective sce-nario. The choice of surgical approach depends on the patient\'s status, hernia characteristics, surgeons and patient preferences. Whether age criteria should be considered when selecting between the two approaches is still a matter of debate. Considering that there is no consensus regarding the best repair in bilateral inguinal herniorrhaphy, the aim of the study is to perform an analysis regarding elective surgical approach of patients with bilateral inguinal hernias. Material and Methods: To study the relationship between exposure to an open versus laparoscopic approach in patients with bilateral inguinal hernia, we conducted a case-control study. In our retrospective analysis, cases (23 patients) were the open-approach hernia repair, and controls (82 patients) were laparoscopic hernia repair. We analyzed two sets of variables: first, related to patient characteristics (age 65 years, BMI 30 kg/m2, smoking habit, HTA status, COPD status, DM status, use of anticoagulants, presence of neoplastic status) and second, variables related to hernia features (inguinoscrotal hernia, recurrent hernia and complicated hernia). Results: The mean age for cases was 73.26 (Ã+-12.99) years and that of controls, was 56.48 (Ã+-15.15) years. Univariate analysis demonstrated four variables with statistical significance: age 65 years, inguinoscrotal hernia, neo-plastic status, and anticoagulant use. When introduced into the multivariate analysis, we noted that only two variables, age 65 years (OR=4.183, 95% CI [1.289, 13.572], p=0.017) and use of anticoagulants (OR=38.876, 95% CI [1.305, 1158.011], p=0.035) reached statistical significance. Conclusion: This study demonstrates that when we refer to bilateral inguinal hernia repair, patients aged 65 years are at risk of having an open procedure at least fourfold more than patients aged 65 years. In addition, the use of anticoagulants increases the risk of open hernia repair 38 times more than that of minimally invasive repair for the same age group. Interestingly, in our study, hernia characteristics were not found to be associated with open hernia repair and age 65 years. In our study we found that age 65 years is associated with electing open hernia repair over minimally invasive repair, which can be linked to age-related risk factors. Further re-search is needed to investigate the impact of age and age-related risk factors on surgical outcomes of bilateral inguinal hernia repair.

The effects of hernia repair on testicular function remain uncertain, regardless of the technique used. Studies that analyze testicular volume and flow after hernia repair or hormonal measurements are scarce and show contradictory results. This study aimed to evaluate the impact of bilateral inguinal hernia repair on male fertility in surgical patients in whom the Lichtenstein and laparoscopic transabdominal preperitoneal (TAPP) techniques were used.
A randomized clinical trial comparing open (Lichtenstein) versus laparoscopic (TAPP) hernia repair using polypropylene mesh was performed in 48 adult patients (20 to 60 years old) with primary bilateral inguinal hernia. Patients were evaluated preoperatively and 90 and 180 postoperative (PO) days. Sex hormones (Testosterone, FSH, LH and SHGB) analysis, testicular ultrasonography, semen quality sexual activity changes and quality of life (QoL) were performed. Postoperative pain was evaluated using the visual analog scale (VAS).
Thirty-seven patients with aged of 44 ± 11 years were included, 19 operated on Lichtenstein and 18 operated on TAPP. The surgical time was similar between techniques. The pain was greater in the Lichtenstein group on the 7th PO day. The biochemical and hormonal analyses, testicular ultrasonography (Doppler, testicular volume, and morphological findings) and sperm quality were similar between groups. However, the sperm morphology was better in the Lichtenstein group after 180 days (p < 0.05 vs. preoperative) and two patients who underwent Lichtenstein hernia repair had oligospermia after 180 days. The QoL evaluation showed a significant improvement after surgery in the following domains: physical function, role emotional, bodily pain and general health (p < 0.05). On comparison of Lichtenstein vs. TAPP none of the domains showed statistically significant differences. No patient reported sexual changes.
Bilateral inguinal hernia repair with polypropylene mesh, whether using Lichtenstein or TAPP, does not impair male fertility in terms of long-term outcomes.
Approved by the Ethics Committee for the Analysis of Research Projects (CAPPesq) of the HC/FMUSP, Number 2.974.457, in June 2015, Registered on Plataforma Brasil in October 2015 under Protocol 45535015.4.0000.0068. Registered on Clinicaltrials.gov, NCT05799742. Enrollment of the first subject in January 2016.

Background: Surgical repair of inguinal hernia is among the most commonly performed surgical interventions in general surgery clinics, with minimal postoperative complications, less pain, and maximum cosmetic results. The aim of this study is to compare the outcomes of patients who underwent Lichtenstein repair (LR), which is currently the most commonly used open surgical procedure to repair inguinal hernias, and laparoscopic totally extraperitoneal (TEP) repair with regard to postoperative cosmesis, patient satisfaction, pain, and inflammatory response. Patients and Methods: The study consisted of male patients 18-65 years of age, who were operated for inguinal hernia with two different methods between February 2022 and January 2023 in the general surgery clinic of Elazig Fethi Sekin City Hospital. C-reactive protein (CRP), white blood cell, and interleukin 6 (IL-6) levels were observed to evaluate the inflammatory response in all patients. Visual Analog Scale and Verbal Rating Score systems were used to monitor the response to pain in the postoperative period. In addition, both groups were evaluated for patient satisfaction in cosmetic terms using the Vancouver Scar Scale and the Modified Stony Brook Scar Evaluation Scale. Results: Postoperative pain sensation in the TEP group was found to be significantly lower compared to the LR group. In terms of inflammatory response, IL-6 and CRP levels were found to be significantly higher in the LR group on postoperative day 1 and 2. Satisfaction with the cosmetic appearance of the surgical scar was significantly higher in the TEP group. Conclusion: TEP, which is a laparoscopic hernia repair method, is a safe surgical technique that can be preferred, especially in patients with less postoperative pain and higher cosmetic expectations. In terms of inflammatory response, significant difference is also in favor of TEP repair.

Groin hernia repair is one of the most frequent operation performed worldwide. Chronic postoperative inguinal pain (CPIP) is the most common and challenging complication after surgical repair with subsequent high socio-economic impact. The aim of this study was to compare the one-year CPIP rates between Lichtenstein, trans-inguinal pre-peritoneal (TIPP), trans-abdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP) repair techniques on the French Hernia Registry.
Between 2011 and 2021, 15,161 primary groin hernia repairs with 1-year follow-up were available on the register. Using propensity score (PS) matching, matched pairs were formed. Each group was compared in pairs independently; Lichtenstein versus TIPP, TEP and TAPP, TIPP versus TEP and TAPP and finally TEP versus TAPP.
After PS matching analysis, Lichtenstein group showed disadvantage over TIPP, TAPP and TEP groups with significantly more CPIP at one year (15.2% vs 9.6%, p < 0.0001; 15.9% vs. 10.0%, p < 0.0001 and 16.1% vs. 12.4%, p = 0.002, respectively). The 1-year CPIP rates were similar comparing TIPP versus TAPP and TEP groups (9.3% vs 10.5%, p = 0.19 and 9.8% vs 11.8%, p = 0.05, respectively). There was significantly less CPIP rate after TAPP versus TEP repair (1.00% vs 11.9%, p = 0.02).
This register-based study confirms the higher CPIP risk after Lichtenstein repair compared to the pre-peritoneal repair techniques. TIPP leads to comparable CPIP rates than TAPP and TEP repairs.

<b> Introduction:</b> Lichtenstein hernioplasty has been a gold standard of hernioplasty for 30 years now. However, the procedure may be followed by an unacceptably high rate of chronic pain, numbness and discomfort. </br></br> <b>Aim:</b> To compare outcomes of Lichtenstein repair using a Parietene ProGrip self-fixing mesh versus the standard lightweight macroporous mesh. </br></br> <b>Material and methods:</b> As many as 141 patients with unilateral primary inguinal hernia participated in this single-centre, randomised, prospective, single-blind (patient-blinded) study. Randomisation yielded two treatment groups: control group of 88 patients treated with Lichtenstein method using lightweight standard mesh (LS) and study group of 53 patients receiving treatment with self-fixing mesh (PG). Patients were followed up for 6 months. Primary outcome was the presence and severity of postoperative pain at discharge, at 30 days and 6 months post-procedure. Other study parameters were: duration of the procedure, duration of hospitalisation, presence of early and late complications, time needed to return to full activity and patient satisfaction. </br></br> <b>Results:</b> No statistically significant differences in pain severity were demonstrated at discharge or at long-term follow-up. In the first 30 days post-procedure the patients in the PG group complained of pain of greater severity on the NRS (2.0 vs 1.4) (P = 0.0466). The duration of the procedure in the PG group was 9.4 minutes shorter than in the LS group (P = 0.0027). No statistically significant differences between the groups were found in other studied parameters. </br></br><b>Conclusions:</b> Self-fixing mesh can be safely used in inguinal canal repair procedures. It significantly shortened the duration of the procedure but at the same time did not reduce the severity of pain, including the rate of chronic postoperative inguinal pain.

The Lichtenstein hernioplasty has long been seen as the gold standard for inguinal hernia repair. Unfortunately, this repair is often associated with chronic pain, up to 10-35%. Therefore, several new techniques have been developed, such as the transinguinal preperitoneal patch (TIPP) and the endoscopic total extraperitoneal (TEP) technique. Several studies showed beneficial results of the TIPP and TEP compared to the Lichtenstein hernioplasty; however, little is published on the outcome when comparing the TIPP and TEP procedures. This study aimed to evaluate outcomes after the TIPP vs the TEP technique for inguinal hernia repair.
A single-center randomized controlled trial was carried out between 2015 and 2020. A total of 300 patients with unilateral inguinal hernia were enrolled and randomized to the TIPP- or TEP technique. Primary outcome was chronic pain (defined as any pain following the last 3 months) and quality of life, assessed with Carolinas comfort scale (CCS) at 12 months. Secondary outcomes were: wound infection, wound hypoesthesia, recurrence, readmission within 30 days, and reoperation.
A total of 300 patients were randomized (150 per group). After a follow-up of 12 months, we observed significantly less postoperative chronic groin pain, chronic pain at exertion, wound hypoesthesia, and wound infections after the TEP when compared to the TIPP procedure. No significant differences in quality of life, reoperations, recurrence rate, and readmission within 30 days were observed.
We showed that the TEP has a favorable outcome compared to the TIPP procedure, leading to less postoperative pain and wound complications, whereas recurrence rates and reoperations were equal in both the groups.

Introduction To date, Lichtenstein tension-free mesh hernioplasty is being adopted widely for inguinal hernia repair in adults, although it is accompanied by procedural complications such as recurrences, infection, testicular atrophy, post-operative pain, and nerve injury. As the recurrence rate decreased after Lichtenstein\'s tension-free hernioplasty, surgeons\' point of focus shifted more toward postoperative groin pain (inguinodynia) after inguinal hernia repair, as it has become a quite significant problem. The nerves of interest in the inguinal region are ilioinguinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves. Out of all the nerves, the ilioinguinal nerve is at the greatest risk of entrapment during meshplasty. Chronic groin pain is quite significant following hernia repair, and irrespective of the severity, it can interfere with normal daily activity. The traditional surgical technique recommends the preservation of the ilioinguinal nerve to avoid the morbidity associated with the cutaneous sensory loss supplied by the nerve. One popular belief is that if we excise the ilioinguinal nerve, then the chance of getting post-operative neuralgia due to entrapment, inflammation, neuroma, or fibrotic reactions will almost become zero. Hence, this study was conducted to evaluate the effect of prophylactic excision of the ilioinguinal nerve in the patients undergoing Lichtenstein hernioplasty for inguinal hernias. Methods All consecutive male patients presenting to the Department of Surgery with inguinal hernia and age above 18 years were included in the study. All the patients were operated on under spinal anesthesia. Lichtenstein tension-free hernia repair was taken as the standard procedure for hernia repair. Patients in whom the nerve was preserved were kept in group A, whereas group B comprised patients who had undergone neurectomy. Patients were followed up regarding pain at first, third, and sixth months, at rest, and after exercise. The pain was graded according to the VAS (visual analog scale) scoring. Results In the present study, out of a total of 92 patients, 80 patients were included. In the first month, 15% of the patients in group A had mild pain, while 5% in group B had experienced a moderate degree of pain at rest. After exercise, the result was 30% in group B. Similarly, in the third month of follow-up, it was found that 25% of the patients in group A experienced mild pain, while 12.5% complained about a moderate degree of pain who had to take analgesics for a longer period. After putting them to exercise and then grading the pain, it was found that 32.5% in group A and 15% in group B experienced pain. After follow-up for six months in both groups, it was revealed that there was no significant difference in post-operative pain at rest (10% and 7.5% in groups A and B, respectively). After exercise, 20% of patients in group A complained of pain, while in group B, only 10% experienced pain. There was no significant difference between both the groups while comparing chronic groin pain at rest and after exercise, and after different time intervals in follow-up (p = 0.4513 and 0.548, respectively). Conclusion Prophylactic excision of the ilioinguinal nerve in Lichtenstein tension-free meshplasty decreased the incidence of chronic groin pain after surgery but it was statistically insignificant. Furthermore, this procedure did not affect the quality of life after surgery.

BACKGROUND: Worldwide, inguinal hernia repair is one of the commonest surgeries. The best treatment option to primary hernia has been investigated, but there still remains lack of evidence about the ideal approach. Therefore, this study aimed to compare the outcomes of inguinal hernia repair using transabdominal preperitoneal procedure (TAPP) & Lichtenstein techniques.
METHODS: This was a retrospective cohort study, conducted at Department of General & Minimal Invasive Surgery, SKIMS Medical College, Bemina, Srinagar. For performing the analysis, we used SPSS. Continuous variables were expressed as mean and standard deviation, and the categorical ones were presented as frequencies and percentages.
RESULTS: A total of 60 patients were included (30 in each group). The mean age of the patients in both groups was around 54 years, and all patients were males. In unilateral cases the operating time was greater in the TAPP group than the Lichtenstein group (p < 0.001); however, in the bilateral cases, the operating time was significantly greater in the Lichtenstein than the TAPP group (p = 0.003). The pain scores, in unilateral cases, were significantly lower in the TAPP group than the Lichtenstein group (p < 0.001). The overall complication rate in the TAPP group was 6.7% while in the Lichtenstein group it was at 23.3%. In unilateral and bilateral cases, the patients significantly returned to work earlier in the TAPP group than those in the Lichtenstein group (p < 0.001).
CONCLUSIONS: TAPP and Lichtenstein techniques are both safe and reliable techniques for inguinal hernia repair. However, TAPP repair showed lesser post-operative pain, earlier discharge from the hospital, earlier return to usual activities, better cosmetic outcomes, and less persisting pain. However, there was no significant difference in the complication rate and TAPP repair was more costly for the patient.