UNASSIGNED: \"Laparoscopic Total Extraperitoneal (TEP)\" repair of hernia is a common surgical procedure for treating groin hernias. This study focused on the long-standing assessment of \"quality of life (QoL),\" chronic pain, and recurrence to compare the effectiveness of TEP hernia surgery with \"mesh fixation (MF)\" against \"nonfixation (NF)\" in patients who are obese with a BMI of 35 kgs/m2 or higher.
UNASSIGNED: In this study\'s randomized controlled experiment, 73 obese individuals with groin hernias underwent total extraperitoneal hernia repair with either MF (n = 35) or NF (n = 38). A check-up was conducted 1, 3, and 5 years after the operation. Recurrence, chronic pain, and QoL were assessed using a physical examination and validated questionnaires.
UNASSIGNED: There were no changes between the subjects of either group in baseline characteristics, hernia recurrence rate, chronic pain rate, or QoL. There were neither significant variations in surgical complications nor hospital stay duration.
UNASSIGNED: The results suggest that treating TEP hernias among people with a BMI of 35 kgs/m2 or above with mesh NF may be successful. The recurrence rates among the subject groups were not substantially different; however, NF was linked with reduced rates of chronic pain which would be beneficial for patient satisfaction and recovery. To decide the optimal technique for MF in TEP hernia repair, these findings need to be verified by additional studies.

OBJECTIVE: The objective of this retrospective study was to assess safety and comparative clinical effectiveness of laparoscopic inguinal hernia repair (LIHR) and robot-assisted inguinal hernia repair (RIHR) from multi-institutional experience in Taiwan.
METHODS: Medical records from a total of eight hospitals were retrospectively collected and analyzed. Patients primarily diagnosed of inguinal hernia, recurrent inguinal hernia or incarceration groin hernia patients who either underwent laparoscopic or robot-assisted inguinal hernia repair between January 2018 and December 2022 were included in the study. Baseline characteristics, intra-operative and post-operative results were analyzed. To compare two cohorts, overlap weighting was employed to balance the significant inter-group differences. We also conducted subgroup analyses by state of a hernia (primary or recurrent/incarceration) and laterality (unilateral or bilateral) that indicated complexity of surgery.
RESULTS: A total of 1,080 patients who underwent minimally invasive inguinal hernia repair from 8 hospitals across Taiwan were collected. Following the application of inclusion criteria, there were 279 patients received RIHR and 763 patients received LIHR. In the baseline analysis, RIHR was more often performed in recurrent/incarceration (RIHR 18.6% vs LIHR 10.3%, p = 0.001) and bilateral cases (RIHR 81.4 vs LIHR 58.3, p < 0.001). Suturing was dominant mesh fixation method in RIHR (RIHR 81% vs LIHR 35.8%, p < 0.001). More overweight patients were treated with RIHR (RIHR 58.8% vs LIHR 48.9%, p = 0.006). After overlap weighting, there were no significant difference in intraoperative and post-operative complications between RIHR and LIHR. Reoperation and prescription rates of pain medication (opioid) were significantly lower in RIHR than LIHR in overall group comparison (reoperation: RIHR 0% vs. LIHR 2.9%, p = 0.016) (Opioid prescription: RIHR 3.34 mg vs LIHR 10.82 mg, p = 0.001) while operation time was significantly longer in RIHR (OR time: RIHR 155.27 min vs LIHR 95.30 min, p < 0.001).
CONCLUSIONS: This real-world experience suggested that RIHR is a safe, and feasible option with comparable intra-operative and post-operative outcomes to LHIR. In our study, RIHR showed technical advantages in more complicated hernia cases with yielding to lower reoperation rates, and less opioid use.

BACKGROUND: International guidelines of groin hernia treatment strongly recommend to fixate the mesh in large M3 medial defects during TAPP/TEP procedures. The main purpose of fixation is to decrease the recurrence rate which is alarmingly high in case of those defects. In 2022, a team consisting of hernia surgeons and scientists from universities of technology conducted an experimental study with the use of 3D groin model to verify the hypothesis that fixation is not necessary in above cases. Experiment showed that rigid and anatomically shaped meshes are able to maintain its position in the groin without fixation. Similar conclusions were recently published in Swedish database registry analysis. To confirm above results, we decided to conduct a multicenter randomized controlled trial.
METHODS: Main objective of MEFI Trial is to verify the hypothesis that non-fixation of spatial, standard polypropylene meshes is non-inferior to fixation of flat, polypropylene lightweight meshes in M3 hernias by laparoendoscopic approach. Eleven large surgery centers in Poland having proficiency in laparoendoscopic groin hernia repairs were recruited for this study. Recurrence in 12-month follow-up was set as a primary endpoint. Pain sensation (Visual Analog Scale) and incidence of other complications (hematoma, seroma, SSI) were also noted. Based on the statistical analysis, minimal sample size in both arms was established at 83-102. The first arm (control) consists of patients undergoing a repair with the use of a flat, macroporous mesh with fixation using histoacryl glue. In the second arm, patients will be operated with the use of anatomically shaped, standard-weight mesh without fixation. Study will be double-blinded (patient/surgeon). After the dissection of preperitoneal space, surgeon will open a sealed envelope and find out which technique he will have to perform. Follow-up will be performed by Study Secretary (also blinded to the method used) via phone call 3 and 12 months after surgery.
CONCLUSIONS: Based on experimental study and recent registry analysis, we believe that the recurrence rate in both groups would be on the same level, giving hernia societies a strong argument for amending the guidelines.
BACKGROUND: ClinicalTrials.gov NCT05678465. Registered on 10 January 2023.

Introduction Inguinal hernia is a common surgical problem throughout the world. Currently, the management options available are open mesh hernioplasty and laparoscopic mesh repair. Laparoscopic mesh repair can be performed by either transabdominal preperitoneal (TAPP) repair or totally extraperitoneal (TEP) repair. Many studies comparing the two procedures have been unable to establish the superiority of one procedure over the other and have yielded conflicting results. Thus, we performed this study to compare TAPP and TEP. Aim The aim of this study is to compare the clinical outcomes and safety of laparoscopic TEP and laparoscopic TAPP for inguinal hernia repair. Materials and methods Patients were randomly divided into two groups on the basis of surgical procedures. The first group of patients underwent laparoscopic TAPP mesh repair, and the second group of patients underwent laparoscopic TEP mesh repair. Their intraoperative and postoperative findings were noted. Patients were followed up at regular intervals for up to six months. Results The mean age and mean weight distribution between the two groups were not significant. The duration of surgery needed (in minutes) for TAPP was found to be significantly less compared to TEP. In the TEP group, conversion to open occurred for three subjects (6.7%) while there was no conversion in the TAPP group. Postoperative pain at 24 hrs was found to be higher in TAPP subjects compared to that in TEP subjects, but the difference was statistically insignificant. Tolerance to a liquid diet started few hours after surgery was found to be the same in both groups. Association of the duration of hospital stays with the type of surgery was not significant. Six subjects (13.2%) showed hematoma in the TEP group while five subjects (11%) in the TAPP group showed hematoma after one week of surgery. Eight subjects (17.6%) showed seroma in the TEP group while three subjects (15.4%) in the TAPP group showed seroma after one week of surgery. Two subjects (4.4%) showed superficial wound infection in both the TEP group and TAPP group after one week of surgery. Four subjects each (8.9%) showed scrotal edema in the TEP group as well as the TAPP group after one week of surgery. No subject showed port site hernia without closure of the sheath at one-week, one-month, and six-month follow-up visits. Two subjects (4.4%) each showed groin pain in the TEP group as well as the TAPP group after one week of surgery. There were no instances of bowel obstruction or mesh infection. Conclusion TEP is a more skill-demanding procedure as compared to TAPP and thus takes more time to perform. However, it is superior on account of not breaching the peritoneum. TAPP is favorable for larger hernias. The choice of procedure should be individualized according to the patient\'s characteristics and surgeon\'s preference.

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.

Although international guidelines recommend not fixing the mesh in almost all cases of laparoendoscopic repairs, in case of large direct hernias (M3) mesh fixation is recommended to reduce recurrence risk. Despite lack of high-quality evidence, the recommendation was upgraded to strong by expert panel. The authors conducted a research experiment to verify the hypothesis that it is possible to preserve the mesh in the operating field in large direct hernias (M3) without the need to use fixing materials.
The authors conducted an experiment with scientists from Universities of Technology in a model that reflects the conditions in the groin area. By simulating conditions of the highest possible intra-abdominal pressure, they examined the mesh behavior within the groin and its ability to dislocate under the forces generated by this pressure. The experiment involved six spatial implants and one flat macroporous mesh.
Heavyweight spatial meshes and lightweight spatial-individualized meshes showed no tendency to dislocate or move directly to the orifice, which was considered a rapid hernia recurrence. Lightweight meshes, both spatial and flat, underwent significant migration and shifting toward the hernial orifices.
Based on the results, we believe that mesh fixation is not the only alternative to preventing recurrence in complex defects. Similar effects can be achieved using a larger, more rigid, and anatomically fitted implant. The type of implant (rather than its fixation) seems to be a key factor from the point of view of mechanics and biophysics. Clinical trials confirming the results in vivo will allow to supplement or amend the guidelines for the treatment of large inguinal hernias.

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 Laparoscopic inguinal hernia repair is the most commonly performed surgery in many hospitals. This study aimed to compare the outcome of the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques in unilateral, uncomplicated inguinal Hernia. Material and methods This prospective randomized study was conducted in a tertiary care hospital in North India from November 2018 to March 2020. Sixty-eight male patients of unilateral, uncomplicated inguinal hernia were enrolled for laparoscopic hernia repair. The first group of 34 patients underwent TAPP repair and the second group of 34 patients underwent TEP repair under general anesthesia (GA). Both groups were compared for intraoperative or postoperative complications, analgesic requirements, postoperative pain, length of hospital stay, resumption of routine activity, and patient satisfaction scores. Fisher\'s exact test or Chi-square test were used for nominal data and the median or interquartile range was used for ordinal data. Results The mean operative time for TAPP was more than that for the TEP group (101 vs 76, p<0.001). The TAPP group exhibited significantly less postoperative pain at six hours, 24 hours and seven days than TEP (p<0.001) and an insignificant difference at three months of the follow-up period (p=0.188). Additional analgesics requirement was less in the TAPP group, although the difference was not significant (p=0.099). Seroma formation was found in four patients (11.8%) in the TEP group and two patients (5.9%) in the TAPP group (p= 0.672). Length of postoperative hospital stay (p=0.907), resumption of routine activity (p=0.732), and patient satisfaction scores (p=0.492) during follow-up were similar in both groups and were also insignificant. Conclusion The TAPP technique is slightly better than TEP for inguinal hernia in terms of lesser postoperative pain with similar chances of complications and other outcomes.

BACKGROUND: Since its introduction, robotic surgery has been utilized in different types of surgeries over various specialties. However, studies done thus far comparing robotic (Rob. IHR) and laparoscopic inguinal hernia repair (Lap. IHR) yielded contrasting results.
OBJECTIVE: This study evaluates the outcomes of adapting the robotic platform for IHR by a single experienced surgeon, comparing it to laparoscopic inguinal hernia repair (Lap. IHR) performed at same time period.
METHODS: Retrospective analysis of a prospectively maintained database including all patients that underwent IHR between 2017 and 2019 (n = 188) was performed. Analyzed data included patient demographics, hernia characteristics, intraoperative data and postoperative outcomes.
RESULTS: Patients (n = 188) underwent a total of 120 Rob. IHR and 157 Lap. IHR. Age, sex, BMI, ASA score and length of hospital stay were similar in both groups. Recurring hernias were repaired more often robotically (p = 0.001). Operative time was significantly longer using the robot. (78.8 ± 24 min vs 55.4 ± 17.4 min for unilateral) and (107.9 ± 30 min vs 62.6 ± 20.2 min for bilateral) Rob. IHR vs Lap. IHR respectively, p < 0.001. Rob. IHR operative time decreased while building a learning curve. Rates of simple and severe postoperative complications were similar, p = 0.414. Recurrence occurred once in Rob. IHR group (1.4%) and 3 times in the Lap. IHR (1.9%) (p = 0.642).
CONCLUSIONS: Our series shows that Rob. IHR is safe with comparable outcomes to Lap. IHR even in early learning curve. Robotic inguinal hernia repair allows the buildup of a short, safe and efficacious robotic learning experience for the minimally invasive surgeons for future more complex robotic surgeries.

BACKGROUND: Laparoscopic surgical approaches, including total extraperitoneal repair (TEP), have been widely accepted for inguinal hernia repair in Japan. However, there are limited data regarding recurrence after TEP in Japan, given the limited versatility of this procedure. This study retrospectively evaluated the rates of hernia recurrence after TEP and open mesh repair at multiple Japanese centers.
METHODS: This retrospective study evaluated 1917 patients who underwent inguinal hernia repair at 32 institutions in the Oita prefecture between January 2014 and December 2015. Eligible patients were grouped according to whether they underwent TEP (1011 patients) or open mesh repair (636 patients). Propensity score matching was performed 1:1 (total: 1076 patients, 538 patients from each group). The outcomes of interest were recurrence, morbidity, and postoperative recovery.
RESULTS: The TEP and open mesh repair groups had similar baseline characteristics. After propensity score matching, there was no significant difference between the two groups in terms of recurrence rate (TEP: 0.5% vs open mesh repair: 1.0%, P = .375). However, the TEP group had significantly longer operating times (median: 70.2 min vs 65.0 min, P < .001), significantly less blood loss (0-5.1 mL vs 0-20.4 mL, P < .001), and significantly shorter postoperative hospital stays (median: 5.0 days vs 6.4 days, P < .001). The overall incidences of morbidity were 6.2% in the TEP group and 7.2% in the open mesh repair group (P = .535).
CONCLUSIONS: This multicenter retrospective study with propensity score matching revealed that the recurrence rates were similarly low for TEP and open mesh repair of inguinal hernia. Thus, a well-trained surgical team could use TEP as a standard procedure.