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 ¤ Patients and methods
 ¤ Results
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 Table of Contents     
Year : 2014  |  Volume : 10  |  Issue : 4  |  Page : 197-201

Single site and conventional totally extraperitoneal techniques for uncomplicated inguinal hernia repair: A comparative study

1 Urologic Department, Faculdade de Medicina do ABC, Santo Andre, SP, Brazil
2 General Surgery Department, Mayo Clinic, Rochester, Minnesota, United States

Date of Submission02-Apr-2013
Date of Acceptance10-Sep-2013
Date of Web Publication23-Sep-2014

Correspondence Address:
Felipe Araujo
62/1902 Evaristo da Veiga street, . Casa Amarela, CEP: 52070-100, Recife
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-9941.141521

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 ¤ Abstract 

Objective: To demonstrate the feasibility of endoscopic extraperitoneal single site (EESS) inguinal hernia repair and compare it outcomes with the conventional totally extraperitoneal (TEP) technique. Background : TEP inguinal hernia repair is a widely accepted alternative to conventional open technique with several perioperative advantages. Transumbilical laparoendoscopic singlesite surgery (LESS) is an emerging approach and has been reported for a number of surgical procedures with superior aesthetic results but other advantages need to be proven. Patients and Methods : Thirty-eight uncomplicated inguinal hernias were repaired by EESS approach between January 2010 and January 2011. All procedures were performed through a 25 cm infraumbilical incision using the Alexis wound retractor attached to a surgical glove and three trocars. Body mass index, age, operative time, blood loss, complications, conversion rate, analgesia requirement, hospital stay, return to normal activities and patient satisfaction with aesthetic results were analysed and compared with the last 38 matched-pair group of patients who underwent a conventional TEP inguinal hernia repair by the same surgeon. Results: All procedures were performed successfully with no conversion. In both unilateral and bilateral EESS inguinal repairs, the mean operative time was longer than conventional TEP (55± 20 vs. 40± 15 min, P = 0.049 and 70± 15 vs. 55± 10 min, P = 0.014). Aesthetic result was superior in the EESS group (2.88± 0.43 vs. 2.79± 0.51, P = 0.042). There was no difference between the two approaches regarding blood loss, complications, hospital stay, time until returns to normal activities and analgesic requirement. Conclusion: EESS inguinal hernia repair is safe and effective, with superior cosmetic results in the treatment of uncomplicated inguinal hernias. Other advantages of this new technique still need to be proven.

Keywords: Inguinal hernia, laparoscopic, single site surgery, LESS

How to cite this article:
Araujo F, Starling ES, Maricevich M, Tobias-Machado M. Single site and conventional totally extraperitoneal techniques for uncomplicated inguinal hernia repair: A comparative study . J Min Access Surg 2014;10:197-201

How to cite this URL:
Araujo F, Starling ES, Maricevich M, Tobias-Machado M. Single site and conventional totally extraperitoneal techniques for uncomplicated inguinal hernia repair: A comparative study . J Min Access Surg [serial online] 2014 [cited 2021 Dec 3];10:197-201. Available from:

 ¤ Introduction Top

The first description of laparoscopic inguinal hernia repair was in the early 1990s. This approach widely accepted is an alternative to conventional treatment with several advantages: reduction of postoperative pain, a short recovery period, extraperitoneal mesh placement and the possibility to treat simultaneously a contra lateral unexpected hernia. [1],[2]

The laparoscopic technique typically involves three ports ranging from 5 to 10 mm. Every incision and trocar placement poses a risk of bleeding, organ damage, incisional hernia and less desirable cosmetic effect. Transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair have become the most common techniques to treat inguinal hernia. TEP approach has some advantages over TAPP approach, but has proved to be more technically demanding. [3],[4]

Transumbilical laparoendoscopic single site surgery (LESS) is an emerging approach and has been reported for a number of surgical procedures with superior aesthetic results but other advantages need to be proven. [5],[6],[7],[8],[9]

There are few studies demonstrating the feasibility of extraperitoneal single site (EESS) in the treatment of inguinal hernia [3],[10],[11],[12],[13],[14],[15] and there are only two papers comparing single incision and conventional TEP inguinal hernia repair. [16],[17] The aim of this study is to report our initial experience with EESS inguinal hernia repair comparing outcomes with a conventional laparoscopic TEP technique control group of patients.

 ¤ Patients and methods Top

In the period between January 2010 and January 2011, 26 consecutive men with 38 uncomplicated inguinal hernias were included in this study. Diagnosis was made by physical examination or by imaging (ultrasound or computed tomography [CT] scan) in few cases when there was un-certainty. A total of 12 patients had bilateral and 14 had unilateral hernias. Patients with incarcerated, strangulated or recurrent hernia were excluded.

After discussion, risks and benefits of EESS inguinal repair, including the possibility of placing other ports or conversion to conventional TEP approach, an informed consent was signed by every patient.

Comparative Parameters Evaluated

Age, hernia characteristics, body mass index (BMI), operative time, blood loss, complications, conversion rate, days on oral pain medication (minor analgesics) after discharge, hospital stay, return to normal activities and patient satisfaction with aesthetic results were prospectively analysed and compared with matched-pair group of patients who underwent conventional TEP inguinal hernia repair by the same surgeon during October 2008 to December 2009. The data from the matched-pair control group was collected from a prospectively database. In both groups, a scale was used to access satisfaction with the cosmetic results at 3 months post-operatively. On this scale, patients reported subjectively if they were satisfied (3 points), partially satisfied (2 points) or unsatisfied (1 point). Student-t and Fisher's exact tests were used for statistical analysis.

Surgical Technique

Patient is placed at supine position. A single 2.5 cm infraumbilical skin incision is used. The anterior sheath of rectus abdominal fascia is opened with a 3 cm transverse incision to gain access to pre-peritoneal space. Digital dissection and followed by balloon dilator inflation permits development of a working space and identification of important landmarks. After creation of pre-peritoneal working space, an Alexis retractor (Applied medical systems, Rancho Santa Margarita, CA, USA) is placed to achieve maximum circumferential retraction of the fasciotomy and skin incision [Figure 1]. To prevent gas leak, a surgical glove is attached to the Alexis retractor and three conventional laparoscopic trocars secured through to each finger of the glove [Figure 2]. A rigid, 10 mm zero degree optic scope and two 5 mm conventional laparoscopic instruments are utilised [Figure 3]. Hernia repair is performed using a 15 × 12 cm polypropylene mesh, which is fixed by applying titanium tacks at the iliopubic tract and Cooper ligament [Figure 4]. The fascia is closed with 0 Vicryl suture and the skin is closed with subcuticular 4-0 monocryl suture. In order to achieve better ergonomics, the surgeon operated from contralateral hernia side.
Figure 1: Alexis retractor

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Figure 2: Alexis retractor and 3 conventional laparoscopic trocars

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Figure 3: Dissection

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Figure 4: Mesh fixed

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 ¤ Results Top

EESS group was completed successfully in all the 26 patients. No procedure was converted to conventional TEP or open procedure. Comparative demographics with EESS and conventional TEP groups are described in [Table 1]. The EESS and matched-pair groups were comparable regarding to BMI, age and hernia characteristics. Comparative perioperative data can be seen in [Table 2]. Mean operative time was longer in the EESS group (unilateral: 53.9± 11.6 vs. 39± 9.07, P: 0.049 and bilateral: 66.79± 9.73 vs. 53± 7.89 min, P: 0.014). Other variables such as blood loss, hospital stay, days of oral pain medications used and recovery time were similar between groups. There were no recurrence in both groups but the mean follow up was shorter in EESS patients (15.5± 3.38 vs. 25.5± 4.38 months, P < 0.01). The complication rate was similar between groups (11.5% vs. 12.5%). No major complications occurred in neither of groups. In the EESS group, there was a epigastric artery injury in one patient, which required clipping for hemostasis. One patient had a seroma and another had a wound hematoma, and both were treated successfully conservatively. Regarding aesthetic results, we found a statistically significant difference favouring the EESS group (2.88± 0.43 vs. 2.79± 0.51, P: 0.042).
Table 1: Patient and hernia characteristics

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Table 2: EESS versus conventional TEP inguinal hernia repair

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 ¤ Discussion Top

Several studies including meta-analysis show that when compared with open conventional mesh repair, laparoscopic surgery offers the advantages of minimally invasive approach with the same long-term results. The benefits were apparent in cases of bilateral surgery or disease recurrence. [1],[2]

LESS is a new minimally invasive technique aiming to reduce morbidity, improve aesthetic outcomes and maintain the optimal results of convention laparoscopic surgery. [8] The application of LESS is growing but there is lack of data regarding the safety and efficacy of this procedure.

The need for advanced minimally surgery skills and the use of only one port instead of three are obstacles that might prevent a wide dissemination of this technique.

New basic concepts such as of loss of triangulation, reduced freedom of movements and cross of instruments are important to understand in order to master this technique. Initial balloon dilation seems to extraordinarily facilitate the dissection and creation of an adequate working space. A Gelport device (Applied medical systems, CA, USA) could be attached to the Alexis retractor and allow application of special ports and conventional trocars in different positions facilitating the EESS access with better manoeuvrability of conventional instruments. In our opinion, the use of Gelport on EESS hernia repair cases allow immediate clinical application for surgeons with basic laparoscopic skills. The use of Alexis and a surgical glove is a similarly effective but cheaper option.

The main question to be addressed is if the EESS technique has some post-operative or functional advantages compared with the conventional TEP 3 port access repair. Some recent publications demonstrate that beyond the improved cosmetic outcomes, the LESS approach might be superior to the conventional TEP approach with less postoperative pain, lower need for analgesia, shorter hospital stay and convalescence in various types of surgical procedures, although most of this data still remains controversial. [8],[18],[19],[20],[21] Another topic for discussion is the risk of port site incisional hernia using one 2.5 cm incision, instead of three smaller incisions. In our opinion, a 2.5 cm skin incision would give a better exposure for fasciotomy closure instead of 1 or 1.5 cm incision, where limited visualisation could lead to a suboptimal closure of the fascia, but this still needs to be proven and studied in our long-term follow-up.

There were no conversions to the TEP conventional approach. As expected, initial experience with EESS procedure is more time consuming compared with the conventional TEP technique. Considering the learning curve, operative time is expect to be reduced with accumulative experience as demonstrated by other papers. [16],[17] Vascular complications could be caused by more challenging dissection in EESS but can also occur in any other technique. Careful manipulation and dissection of epigastric vessels and spermatic cord can prevent this complication. Major complications were not observed in our series. Post-operative bleeding, analgesia, hospital stay and recovery for normal activities were similar to our results obtained using the conventional TEP technique.

The number of patients satisfied with the cosmetic results was high in both groups but statistically higher in the EESS group. Although this is not the most important outcome considered, some patients more concerned with body image could be considered when choosing possible surgical options.

To our knowledge, there are only two papers comparing EESS versus conventional TEP inguinal hernia repair. [16],[17] In agreement with our results, despite a longer operative time in the EESS group, all other variables were comparable between the two techniques. Aware of our short follow-up, our study focuses on early outcomes, safety, feasibility and reproducibility of this new technique. Our plan is to continue to follow-up on these patients and report our long-term results in the future.

Considering our results, we believe that EESS inguinal hernia repair is safe and effective to treat uncomplicated hernia, with better aesthetic satisfaction. Further studies with larger series and longer follow-up are necessary to establish the future application of EESS in the treatment of inguinal hernia.

 ¤ References Top

1.Feliu X, Clavería R, Besora P, Camps J, Fernánds-Sallent E, Viñas X, et al. Bilateral inguinal hernia repair: Laparoscopic or open approach. Hernia 2011;15:15-8   Back to cited text no. 1
2.Arregui ME, Young SB. Groin hérnia repair by laparoscopic techniques: Current status and controversies. World J Surg 2005;29:1052-7   Back to cited text no. 2
3.Cugura JF, Kirac I, Kulis T, Jankoviæ J, Beslin MB. First case of single incision laparoscopic surgery for totally extraperitoneal inguinal hernia repair. Acta clin croat 2008;47:249-52.  Back to cited text no. 3
4.Dulucq JL, Wintriger P, Mahajna A. Laparoscopic totally extraperitoneal inguinal hernia repair: Lessons learned from 3.100 hernia repair over 15 years. Surg Endosc 2009;23:482-6.  Back to cited text no. 4
5.Remzi FH, Kirat HT, Kauok JH, Geisler DP. Single-port laparoscopy in colorectal surgery. Colorectal Dis 2008;10:823-6.  Back to cited text no. 5
6.Tome AL, Tobias-Machado M, Correa WF. Laparoendoscopic single-site (LESS) sacrocolpopexy: Feasibility and efficacy of knotless procedure performed with conventional instruments. Int Urogynecol J Pelvic Floor Dysfunct 2011;22:885-7.   Back to cited text no. 6
7.Choi KH, Ham WS, Rha KH, Lee JW, Jeon HG, Arkoncel FR, et al. Laparoendoscopic single-site surgeries: A single-center experience of 171 consecutive cases. Korean J Urol 2011;52:31-8.  Back to cited text no. 7
8.Canes B, Berger A, Aron M. Laparoendoscopic single site (LESS) versus standard laparoscopic donor nephrectomy: Matched-pair comparison. Eur Urol 2010;57:95-101.  Back to cited text no. 8
9.Raman JD, Bagrodia A, Cadeddu JA. Single-Incision umbilical laparoscopic versus conventional laparoscopic nephrectomy: A comparison of perioperative outcomes and short-terms measures of convalescence. Eur Urol 2009;74:805-12.  Back to cited text no. 9
10.Agrawal S, Shaw A, Soon Y. Single port laparoscppic totally extraperitoneal inguinal hernia repair with the three port system: Initial experience. Surg Endosc 2010;24:952-6.  Back to cited text no. 10
11.Surgit O. Single-incision laparoscopic surgery for total extraperitoneal repair for inguinal hernias in 23 patients. Surg Laparosc Endosc Percutan Tech 2010;20:114-8.  Back to cited text no. 11
12.Do M, Liatsikos E, Beatty J, Haefner T, Dun I, Kallidonis P, et al. Laparoscopic single-site estraperitoneal inguinal hernia repair: Initial experience in 10 patients. J Endourol 2011;25:963-8.  Back to cited text no. 12
13.Tai HC, Ho CH, Tsai YC. Laparoendoscopic single-site surgery: adult hernia mesh repair with homemade single port. Surg Laparosc Endosc Percutan Tech 2011;21:42-5.  Back to cited text no. 13
14.He K, Chen H, Ding R, Hua R, Yao Q. Single incision laparoscopic totally extraperitoneal inguinal hernia repair. Hernia 2010;15:451-3.   Back to cited text no. 14
15.Chung SD, Huang CY, Wang SM, Hung SF, Tsai YC, Chueh SC, et al. Laparoendoscopic single-site totally extraperitoneal adult inguinal hernia repair: Initial 100 patients. Surg Endosc 2011;25:3579-83.  Back to cited text no. 15
16.Tai HC, Lin CD, Chung SD, Chueh SC, Tsai YC, Yang SS. A comparative study of standard versus laparoendoscopic single-site surgery (LESS) totally extraperitoneal (TEP) inguinal hernia repair. Surg Endosc 2011;25:2879-83.  Back to cited text no. 16
17.Cugura JF, Kirac I , Kulis T, Sremac M, Ledinsky M, Beslin MB. Comparison of Single incision laparoscopic totally extraperitoneal and laparoscopic totally extraperitoneal inguinal hernia repair: Initial experience. J Endourol 2012;26:63-6.  Back to cited text no. 17
18.Stein RJ, Berger AK, Brandina R, Patel NS, Canes D, Irwin BH, et al. Laparoendoscopic single-site pyeloplasty: A comparison with the standard laparoscopic technique. BJU Int 2011;107:811-5.   Back to cited text no. 18
19.Saber AA, El-Ghazaly TH, Elain A, Dewoolkar AV. Single-incision laparoscopic placement of an adjustable gastric band versus conventional multiport laparoscopic gastric banding: A comparative study. Am Surg 2010;76:1328-32.  Back to cited text no. 19
20.Saber AA, El-Ghazaly TH, Dewoolkar AV, Slayton SA. Single-incision laparoscopic sleeve gastrectomy versus conventional multiport laparoscopic sleeve gastrectomy: Technical considerations and strategic modifications. Surg Obes Relat Dis 2010;6:658-64.   Back to cited text no. 20
21.Park YH, Park JH, Jeong CW, Kim HH. Comparison of laparoendoscopic single-site radical nephrectomy with conventional laparoscopic radical nephrectomy for localized renal-cell carcinoma. J Endourol 2010;24:997-1003.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]

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