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Outcomes After Laparoscopic Transabdominal Pre-Peritoneal Repair (TAPP) For Groin Hernia In A Single Consultant Series

Aim: TAPP repair is an established minimally invasive approach for groin hernia repair. The objective of this study was to report post-operative outcomes after TAPP repair in a single surgeon series and benchmark these against reported outcomes in the literature. Methods: All patients who had an elective or emergency TAPP repair of a groin hernia from September 2016 to March 2020 in a district general hospital were retrospectively analysed from the electronic care record (ECR) for post-operative morbidity, re-admission, recurrence and length of hospital stay. The primary outcome of interest, chronic post-operative pain, was assessed via telephone interviews using the European Registry for Abdominal Wall Hernias Quality of Life (EuraHS-QoL) questionnaire. Results: 164 patients, incorporating 190 hernia repairs were included. 155 (94.5%) were men and 9 (5.5%) were women. The median age was 51 (range: 20-81). 160 (97.6%) patients had an elective repair and 4 (2.4%) had an emergency repair. 157 (95.7%) patients underwent a primary inguinal hernia repair, of which 26 (15.8%) had a bilateral inguinal hernia repair. 7 (4.3%) patients had a femoral hernia repair. All procedures were performed by a single consultant surgeon. One emergency patient required conversion to open to allow for resection of ischaemic small bowel, however, the hernia itself was repaired laparoscopically. 94 (57.3%) patients were successfully contacted to provide EuraHS-QoL scores. 13/94 patients (13.8%) complained of chronic pain at rest on an average follow-up of 32.7 months (range: 16-43m). 2/94 (2.1%) patients had mild pain, 9/94 (9.6%) had moderate pain and 2/94 (2.1%) patients had severe pain at rest. 131 (79.9%) TAPP repairs were performed as day case procedures. Median length of stay in those patients who were not day cases was 1 day (range=1-11 days). Post-op morbidity rate was 7.9% (n=13), however, these were minor complications (Clavien-Dindo I/II). Incidence of seroma and haematoma was 1.8% (n=3) each. Re-admission rate was 3% (n=5). Mean follow-up of patients was 21 months (SD 12.6m, range=1-43m). Two patients (1.2%) had a recurrent groin hernia during this time period and one patient (0.6%) had a port site hernia. Conclusion: The outcomes of chronic post-operative pain and rate of recurrence were comparable to those reported in the literature. Re-admission rate was low and there were no major complications. The majority of patients were performed as a day case.


Introduction
Minimally invasive techniques (TAPP and TEP (totally extra-peritoneal repair)) for groin hernia repair were first introduced in the early 1980s. 1 Since then, outcomes from these procedures have been extensively reported in the literature. Recurrence rate after laparoscopic repair is comparable to that of open conventional techniques and has been reported to be up to 5%. 2, 3 A multi-centre randomized controlled trial reported incidence of chronic pain following laparoscopic repair to be half that of open Lichtenstein repair at the end of 5 years, 9.4% compared to 18.8%. 4 Both TAPP and TEP are equally popular as established laparoscopic techniques. A detailed review of outcomes following laparoscopic inguinal hernia repair by the HerniaSurge group in 2018 did not show any significant difference in operative times, recovery time, post-operative pain, total complication rates, hospital length of stay, recurrence rates or costs between TAPP and TEP repair. However, access-related complications can differ; there is increased risk of visceral injury during trans-abdominal entry with TAPP while there is increased risk of vascular injury during extra-peritoneal entry and dissection during TEP. 5 The aim of our study was to review the post-operative outcomes in a single consultant surgeon series of TAPP procedures for both an elective and emergency presentation of a groin hernia and benchmark these against accepted published standards. The primary outcome of interest was incidence of chronic post-operative pain. Secondary outcomes were post-operative morbidity, readmission rates, hernia recurrence and length of hospital stay.

Methods
All patients who had an elective or emergency TAPP repair of a groin hernia at our district general hospital from September 2016 to March 2020 by one consultant surgeon were retrospectively analysed for post-operative morbidity, re-admission, hernia recurrence and length of hospital stay. All information was retrieved from electronic care records (ECR) by assessing discharge summaries and any subsequent documents or relevant investigations that may report a recurrence.
All patients presenting with an elective or emergency groin hernia were offered a TAPP repair unless they had a large, irreducible inguinoscrotal hernia when an open repair was offered. A standard 3-port TAPP repair was performed using a flat 15x10cm lightweight, macroporous polyester mesh secured in a standard way with absorbable tacks and the peritoneal flap closed with an absorbable continuous suture.
Chronic post-operative pain was defined as pain occurring more than 3 months after surgery, as per the International Association of the Study of Pain, 6 and was analysed using the European Registry for Abdominal Wall Hernias Quality of Life (EuraHS-QoL) score via telephone interviews. The EuraHS-QoL score is a validated disease-specific, patientreported outcome tool that can be used to quantify pain at the site of the hernia repair, restriction of daily activities and cosmetic discomfort. 7 , 8 We did not have any preoperative scores for this cohort of patients and cosmetic scores were not recorded as it was felt that this outcome is more relevant to major incisional hernia repairs. Reasonable efforts were made to contact initial non-responders on at least 2 further occasions in order to maximise the data obtained.
Descriptive statistics were used to analyse the data in Microsoft Excel (Version 16.16.22). 94 patients were available to provide EuraHS-QoL scores via telephone interviews. Mild pain was defined as score 1 to 3, moderate pain as score 4 to 7 and severe pain as score 8 to 10. Likewise, restriction to daily activities, both indoor and outdoor, and restriction to sports and heavy labour was also stratified as mild (score 1-3), moderate (score 4-7) and severe (score 8-10). Pain and restriction scores of contactable patients are described in detail in Tables 3-6. UMJ is an open access publication of the Ulster Medical Society (http://www.ums.ac.uk). The Ulster Medical Society grants to all users on the basis of a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence the right to alter or build upon the work non-commercially, as long as the author is credited and the new creation is licensed under identical terms.

Discussion
This was a retrospective study which aimed at reporting important surgical outcomes after laparoscopic TAPP repair of groin hernia. The primary outcome of interest was the incidence of chronic post-operative pain. Prevalence of chronic post-operative pain ranges from 1 to 32% in the literature. The incidence of chronic pain in our cohort was 13-16%, of which approximately 5% was reported to be severe by patients. Table 7 shows our rate of chronic pain when compared to other studies. 4,[9][10][11][12][13][14][15][16][17] The lack of a standard definition is primarily responsible for the variable rates of chronic pain reported in the literature. 18 There is good evidence in the literature supporting the superiority of laparoscopic groin hernia repair to open repair with regards to early post-operative pain, analgesia requirement, time to return to normal daily activities and chronic pain. 4,25-29 A recent updated network meta-analysis has reaffirmed these findings: apart from significantly reduced early postoperative pain, time to return to work/activities and chronic pain, minimally invasive TEP and TAPP were also associated with significantly reduced risk of hematoma and wound infection compared to the open Lichtenstein tensionfree repair. However, risk of hernia recurrence and seroma were similar between both groups, so was the post-operative length of hospital stay. 30 In our study, recurrence rate was low and well within rates reported in the literature (Table 8). 4, 9-17, 31, 32 Immediate postoperative morbidity was uncommon and of minor severity. None of the patients required any immediate operative reintervention. The British Association of Day Surgery has suggested that 80% of inguinal hernia repairs should be carried out as day case procedures. 33 This figure was achieved in our cohort.
The 2009 European Hernia Society (EHS) guidelines recommend that bilateral hernia should preferably be treated by a laparoscopic method provided expertise is available. 34 The advantages of laparoscopic repair (faster recovery, lower risk of chronic pain and cost-effectiveness) are increased when performing two hernia repairs via the same approach. The European Association of Endoscopic Surgery (EAES) guidelines also recommend laparoscopic repair to be an excellent choice in bilateral groin hernias. 35 This view is also endorsed by the British Hernia Society groin hernia guidelines. These guidelines also recommend laparoscopic approach to be the preferred method of choice in women, in patients at risk of chronic pain (younger patients, other chronic pain problems, pre-operative presentation of severe groin pain with only a small hernia on palpation) and in patients with a recurrent hernia if the index operation was an open repair. 36 The Department of Health (DoH) Northern Ireland published a policy statement in July 2020 for the proposed establishment of a regional service for day case elective care procedures in Northern Ireland. 37 Elective procedures could therefore be carried out without any competition from emergency procedures, thus reducing the likelihood of last-minute cancellations. Furthermore, at COVID-light or COVID-free facilities, this could also minimise risk to elective patients and allow more effective use of resources. A regional elective service could potentially reduce waiting times for elective procedures that have seen an all-time high as a result of the COVID-19 pandemic. 38 One of the general surgical procedures proposed in the DoH policy statement is primary repair of an inguinal hernia. In view of the arguments put forward in our paper in favour of laparoscopic repair, we propose that the regional elective surgical services in Northern Ireland should consider offering laparoscopic repair at least to the patient groups that are highly likely to benefit from it: young men, women, and bilateral or recurrent hernias. Our data show acceptable levels of chronic pain and hernia recurrence following laparoscopic hernia repair in all patients deemed suitable for a laparoscopic repair and also reaffirm that the figure of 80% day cases is achievable with the laparoscopic approach.
Conflict of Interest: None declared.