Transrectus sheath pre-peritoneal (TREPP) procedure versus totally extraperitoneal (TEP) procedure and Lichtenstein technique: a propensity-score-matched analysis in Dutch high-volume regional hospitals

Abstract

Purpose Results of the most commonly used inguinal hernia repair techniques often originate from expert centers or from randomized controlled studies. In this study, we portray daily-practice results of a high-volume, regional surgical group in the Netherlands, comparing TREPP (open (posterior) transrectus sheath pre-peritoneal) with Lichtenstein (open anterior) and TEP (endoscopic (posterior) totally extraperitoneal). We hypothesize that the TREPP shows more favorable outcome compared to the current gold standard procedures: TEP and Lichtenstein. Methods Between January 2016 and December 2018, 3285 consecutive patients underwent surgical treatment and were included for analysis. The outcome measures were postoperative pain, recurrence rate and other surgical complications. Propensity-score matching was used to address potential selection bias. Results After propensity-score matching, there was no statistically significant difference in postoperative pain in the TREPP group compared to the Lichtenstein group (TREPP 7.3% versus Lichtenstein 6.3%; p = 0.67) nor in TREPP compared to TEP (TREPP 7.4% versus TEP 4.1%; p = 0.064). There was no statistically significant difference in recurrences in the TREPP group compared to Lichtenstein (3.8% vs 2.5%; p = 0.42), nor in the TREPP versus TEP comparison (3.9% vs 2.8%; p = 0.55) Conclusion This study compares TREPP with Lichtenstein and TEP in the presence of postoperative pain, recurrences and other adverse outcomes. After propensity-score matching, no statistically significant difference in postoperative pain or recurrences remained between either TREPP compared to Lichtenstein, or TREPP compared to TEP. Based on these results, TREPP, Lichtenstein and TEP showed comparable results in postoperative pain, recurrences and other surgical site complications.

Open Preperitoneal Inguinal Hernia Repair, TREPP Versus TIPP in a Randomized Clinical Trial

“…With a 1b level of evidence (LoE), 23 this trial is the first to confirm the earlier published promising results after TREPP 8 – 12 and good results after TIPP surgery. 4 , 5 Retrospective TREPP studies report CPIP rates of 1.7% 10 and 5.3% 9 (LoE 3b-4) and recurrence rates of 1.2%, 9 1.7% 10 and 3.9% 11 (LoE 3b-4) with significant follow-up variation (2 weeks–2 years). The more extensive evidence on TIPP surgery, mainly compared to Lichtenstein's technique, shows <5% CPIP rates (LoE 1b–2b), 4 , 5 , 24 – 26 ∼3% recurrence rates (LoE 1b-2b), 4 , 5 , 24 , 25 , 27 and quicker recovery.…”

“…Other TREPP principles are: an open technique with a non-fixated preperitoneal mesh based on the biomechanical upstream principle. 8 Previous retrospective studies were promising [8][9][10][11][12] and contributed to the hypothesis of the ENTREPPMENT trial that less patients would suffer from CPIP after TREPP compared to TIPP.…”

Mesh fixation techniques in Lichtenstein tension‐free repair: a network meta‐analysis

“…It has the advantages of a short operation time, low recurrence rate, flat learning curve and ease of mastery. In addition, the Lichtenstein method can be performed under local anaesthesia, which is more suitable for high‐risk patients and has irreplaceable advantages 6 . The classic Lichtenstein method uses non‐absorbable sutures to fix the mesh 7 .…”

“…In addition, the Lichtenstein method can be performed under local anaesthesia, which is more suitable for high-risk patients and has irreplaceable advantages. 6 The classic Lichtenstein method uses non-absorbable sutures to fix the mesh. 7 A related study has shown that suture fixation may increase the risk of chronic postoperative inguinal pain (CPIP).…”

Posterior mesh inguinal hernia repairs: a propensity score matched analysis of laparoscopic and robotic versus open approaches

“…Studies evaluating TREPP/OPP have thus far been limited, but some single-institution observational studies have shown promising outcomes [10][11][12][13]. Comparisons of TREPP to MIS TEP and open Lichtenstein approaches demonstrate no significant differences in recurrence rates, postoperative complications, or postoperative pain [5,14], and a recent meta-analysis on TREPP demonstrated low risk of recurrence, chronic pain, hematoma, and wound infection [15]. While evaluation of the quality of hernia repair has traditionally involved comparison of recurrence rates, patients themselves also measure the success of their surgery by their quality of life in recovery.…”