Hernia Repair: TEP Bests Lichtenstein in Randomized Trial

Larry Hand

March 19, 2012

March 19, 2012 — When performed by highly experienced surgeons, total extraperitoneal inguinal hernioplasty (TEP) led to less chronic pain, fewer hernia recurrences, and less sensation impairment during a 5-year follow-up period than the more invasive Lichtenstein repair method for hernias, according to study results published in the March issue of the Archives of Surgery.

Hasan H. Eker, MD, a surgeon from the Erasmus Medical Center in Rotterdam, the Netherlands, and colleagues analyzed the experiences of 660 patients (mean age, 55 years) who underwent hernia repair procedures between July 18, 2000, and April 28, 2004, at 6 centers.

Of the 660 patients, 336 were randomly assigned to TEP, a minimally invasive endoscopic procedure, and 324 were randomly assigned to Lichtenstein repair, an open surgery. Surgeons used polypropylene prosthetic meshes for both types of procedure.

After withdrawals, deaths, or other reasons for exclusion, the final number of patients who completed a 5-year follow-up period totaled 228 in the TEP group and 204 patients in the Lichtenstein group. During the follow-up period, 44 patients died (21 in the TEP group and 23 in the Lichtenstein group), but the deaths were not a result of the hernia repair, the researchers write. Postoperative pain was the primary study outcome. Secondary outcome measures included chronic pain at 5 years, recurrence rate, operative costs, operating time, complications, length of hospital stay, and quality of life.

Postoperative pain, measured as presence vs absence of pain at 1, 2, 3, 7, and 30 days after the procedure, was significantly less after TEP than after Lichtenstein repair (23% vs 32%; P = .01).

For chronic pain, the researchers found the incidence rate at 28% for the Lichtenstein group after 5 years compared with 14.9% for the TEP group (P = .004). For sensation, the authors found that 22% of the Lichtenstein group reported impairments compared with 1% of the patients receiving TEP (P < .001).

The experience level of the surgeon turned out to be a major factor: Of the 457 surgeons who reported their experience level, most (402) were highly experienced surgeons. Even when less-experienced surgeons performed TEP, a surgeon who had performed at least 30 hernia procedures endoscopically was required to supervise.

The researchers found that the cumulative hernia recurrence rates were comparable, at 4.9% for the TEP group and 8.1% for the Lichtenstein group (P = .10), but recurrence rates plummeted for procedures performed by experienced surgeons.

"The overall hernia recurrence rate after 5 years for both procedures performed by experienced residents or surgeons (level 3) was significantly lower than that for inexperienced residents or surgeons (level 1) (2.4% vs 14.3%, P = .001)," the researchers write. When they analyzed only TEP procedures, the gap widened even further between recurrence rates for highly experienced surgeons (0.5%) and inexperienced surgeons (25.0%).

When the researchers compared procedures performed only by experienced surgeons or residents, recurrence rates amounted to 0.5% for TEP and 4.2% for Lichtenstein repair (P = .04).

Patient satisfaction ranked 8.5 for the procedure and 8.8 for the operative scar on a scale of 1 to 10 for the TEP group, and 8.0 and 8.4, respectively, for the Lichtenstein group (P = .004 for comparison of procedure satisfaction between the 2 treatment groups, and P = .02 for comparison of scar satisfaction between the 2 groups).

Patients who received the TEP experienced more operative complications (6% vs 2%; P = .001) and longer operating times than patients who received the Lichtenstein procedure, but the researchers write that the positive outcomes "counterbalance" that, and that complications had no long-term effects. Total costs and length of hospital stay turned out to be comparable for both procedures. Patients who received TEP returned to daily activities sooner (P < .002) and had fewer days off from work (P = .001).

Long-term follow-up patient visits occurred at 1 year and 5 years after surgery, at which 2 independent physicians who were unaware of each other's findings actually performed physical examinations.

Compared with other studies into hernia repair procedures, the researchers write that their follow-up period was longer and their methods more precise. "The accuracy of hernia recurrence rates in our study is ensured because every patient in our study had a clinical follow-up visit with physical examination performed by 2 independent physicians," the researchers write.

They conclude, "Postoperative pain in the short term and chronic pain at 5 years after surgery were significantly greater after Lichtenstein repair vs TEP (32% vs 23% and 28% vs 15%, respectively), as was impairment of inguinal sensibility (22% vs 1%). Patients are more satisfied after TEP with the surgical procedure and with their operative scars. Therefore, TEP should be recommended in experienced hands."

The authors have disclosed no relevant financial relationships.

Arch Surg. 2012;147:256-260.


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