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

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

Standards

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

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

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

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

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

Chi-square test P=0.932

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

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

Hospital Stay - Distribution

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

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

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

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

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

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

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

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

Type of Anaesthesia - Open

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

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

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

Thank you