Telescopic Dissection as a Cost-Effective Alternative to Balloon Trocar for Preperitoneal Dissection in Total Extraperitoneal Inguinal Hernia Repair

Abstract

Background:

Total extraperitoneal (TEP) approach is one of the commonly used minimally invasive method in inguinal hernia repair. There are limited data that compares the results of the telescopic dissection and balloon trocar for preperitoneal dissection. In our study, we aimed to retrospectively evaluate the TEP cases performed at our center and compare the results of these two techniques.

Methods:

TEP cases performed between 2020 and 2024 were evaluated. Strangulated and recurrent hernia cases were excluded. Telescopic dissection and balloon trocar techniques were compared in terms of conversion, postoperative pain, complications, and recurrence.

Results:

A total of 177 patients were included. Telescopic method was used in 122 cases, while a balloon trocar was used in 55 cases. The median age was 50 years (range: 20–86), and 163 patients (92%) were male. Bilateral inguinal hernia was present in 61 patients (35%). The median operative time was 100 minutes (IQR: 80–120 minutes). Conversion was required in a total of 3 cases (1.5%); specifically, the transabdominal preperitoneal method was employed in 2 cases, and Lichtenstein-style anterior approach hernia repair was performed in one case. Between the telescopic dissection and balloon trocar groups, no significant differences were observed in operation time (P = .407), conversion rates (P = .228), postoperative pain scores (P = .505, P = .264, P = .681, P = .743), complication rates (P = .205), or recurrence rates (P = .311).

Conclusions:

The results of using a balloon trocar and telescopic dissection in inguinal hernia repair with TEP are similar, and telescopic dissection could be a cost-effective alternative to the balloon trocar.

Introduction

Inguinal hernia repair is among the most commonly performed surgeries in general surgery practice, with an increasing application of minimally invasive approaches. The total extraperitoneal (TEP) approach for inguinal hernia repair is one of the minimally invasive methods that has been utilized since the 1990s^1,2 In this method, it is necessary to create the operative field by dissecting the preperitoneal area, for which both the telescopic method and balloon trocar dissection methods have been described.^1–3 In the 2011 Guidelines of the International Endohernia Society (IEHS), the use of balloon trocars was recommended, particularly during the early learning period.⁴ However, industrial balloon trocars add a cost of approximately $350–600 to the surgery, and covering this cost may be problematic, especially in underdeveloped and developing countries. The study that influenced the recommendation for balloon trocar usage was conducted in 2001, and there are few current publications evaluating the difference between the telescopic method and the use of a balloon trocar.^3,5 In our study, we aimed to present the comparative results of TEP cases, focusing on the dissection of the preperitoneal area using the telescopic method versus the balloon trocar.

Materials and Methods

Study population

A total of 177 patients who underwent TEP for elective inguinal hernia repair at Şişli Hamidiye Etfal Training and Research Hospital between 2020 and 2024 were retrospectively examined. Our study was conducted in accordance with the Declaration of Helsinki and was approved by the Şişli Hamidiye Etfal Training and Research Hospital Clinical Research Ethics Committee on April 30, 2024 (No: 4384).

Patients aged 18 and over who underwent TEP for elective inguinal hernia repair were included. Exclusion criteria included the presence of strangulated or recurrent inguinal hernia. Patients were assessed based on age, gender, unilateral or bilateral hernia, utilization of telescopic dissection or balloon trocar, conversion rates, operative time, length of hospital stay, postoperative pain scores, complications, and recurrence rates. Complications were evaluated using the Clavien–Dindo classification.^6,7

Outcome measures

The primary outcomes assessed in our study were postoperative pain scores, conversion rates, and complication rates. Recurrence rates were evaluated as secondary outcomes.

Surgical technique

In inguinal hernia repair with TEP, the preperitoneal area is accessed by dissecting the posterior aspect of the rectus muscles through a 1 cm infraumbilical incision. The preperitoneal space is then created by using either a telescopic method or a balloon trocar, based on the surgeon’s preference. Following exposure of the entire myopectineal orifice, it is covered with a polyprolene mesh of appropriate size (typically 15 × 15 cm), and the mesh is fixed to the Cooper ligament with 1 or 2 tackers. Hemostasis is confirmed, and the position of the patch is verified before terminating preperitoneal insufflation under direct observation. Postoperative pain is assessed using the numeric rating scale (NRS) during the initial 24 hours.⁷ Patients without complications discharged on first postoperative day. A longer hospital stay may occasionally be necessary for patients experiencing persistent pain or complicated cases. Urinary catheterization before surgery is not routine and is performed based on the surgeon’s discretion.

Statistical analysis

Statistical analysis was performed using SPSS (Statistical Package for the Social Sciences) version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics (numbers, percentages, means, medians, etc.) were used to analyze the study data. The normal distribution was assessed using the Shapiro–Wilk test for numerical data. Mean and standard deviation (SD) were utilized for normally distributed data, while median and interquartile range (IQR) were used for non-normally distributed data. Categorical data were compared using chi-square tests (Pearson’s chi-square, continuity correction, Fisher’s exact test), and numerical data were compared using Student’s t-test or Mann–Whitney U-test. Results were considered significant at p < .05, with a confidence interval of 95%.

Results

A total of 177 patients who underwent inguinal hernia repair using the TEP method at our center between 2020 and 2024 were included in the study. The telescopic method was utilized in 122 patients, while the balloon trocar was used in 55 patients. The median age was 50 years (range: 20–86), with 163 patients (92%) being male. Bilateral inguinal hernia repair was conducted in 61 patients (35%). Conversion was necessitated in a total of 3 cases (1.5%), with 2 cases (1%) requiring completion using the transabdominal preperitoneal (TAPP) method and one case (.5%) with the Lichtenstein method of anterior approach hernia repair. The median duration of surgery was 100 minutes (IQR: 80–120 minutes). Comparing the use of the telescopic method and balloon trocar based on demographic and clinical characteristics, age, gender, presence of unilateral/bilateral hernia, change in surgical technique, and operation time were found to be similar between the two groups (P >.05) (Table 1).

Table 1.

Demographic and Clinical Parameters of the Study Group

Variables	All patients (N = 177)	Telescopic dissection (N = 122)	Balloon trocar (N = 55)	P value
Age (years, median, range)	50 (20–86)	50.5 (39.75–63)	50 (39–61)	.626^a
Gender
Female	14 (8%)	9 (5%)	5 (3%)	.696^b
Male	163 (92%)	113 (64%)	50 (28%)
Unilateral/bilateral
Unilateral	116 (65%)	80 (45.3%)	36 (20.3%)	.988^b
Bilateral	61 (35%)	42 (23.7%)	19 (10.7%)
Alteration in surgical technique
No conversion	174 (98.5%)	121 (68.5%)	53 (30%)	.228^c
TAPP	2 (1%)	1 (.5%)	1 (.5%)
Anterior approach	1 (.5%)	0 (0%)	1 (.5%)
Operation time (minutes, median, IQR)	100 (80–120)	100 (87–121)	95 (70–120)	.407^a

Mann–Whitney U-test.

Chi-square test.

Fisher’s exact test.

IQR, interquartile range; TAPP, trans-abdominal preperitoneal approach.

Postoperative pain scores (NRS, Median, IQR) in all patients were as follows: 5 (4–6) at the 3rd hour, 4 (3–4) at the 6th hour, 2 (2–3) at the 12th hour, and 1 (1–2) at the 24th hour. It was observed that the NRS scores at the 3rd, 6th, 12th, and 24th hours postoperatively did not exhibit any significant difference between the telescopic method and the balloon trocar (P = .505, P = .264, P = .681, P = .743, respectively) (Table 2).

Table 2.

Postoperative Pain Scores

Variables	All patients (N = 177)	Telescopic dissection(N = 122)	Balloon trocar(N = 55)	P value
Postoperative NRS scores (median, IQR)
3 hours	5 (4–6)	5 (4–6)	5 (4–6)	.505^a
6 hours	4 (3–4)	4 (3–4)	4 (3–4)	.264^a
12 hours	2 (2–3)	2 (2–3)	2 (2–3)	.681^a
24 hours	1 (1–2)	1 (1–2)	1 (1–2)	.743^a

Mann–Whitney U-test.

IQR, interquartile range; NRS, mumeric rating scale.

The median duration of hospital stay was 1 day (IQR 1–1). Complications occurred in a total of 12 patients (6%), with 10 (5%) classified as grade 1 and 2 (1%) as grade 2 complications. No grade 3–5 complications were observed in any patient in the study group. There was no significant difference in complication rates between the telescopic method and balloon trocar (P = .205) (Table 3).

Table 3.

Length of Stay, Postoperative Complications, Follow-Up and Recurrences

Variables	All patients (N = 177)	Telescopic dissection (N = 122)	Balloon trocar (N = 55)	P value
LOS (days, median, IQR)	1 (1–1)	1 (1–1)	1 (1–1)	.305^a
Postoperative complications
No complications	166 (95%)	116 (65.5%)	50 (28.5%)	.205^b
Grade 1	10 (5%)	6 (3%)	4 (2%)
Seroma formation	4 (2%)	1 (.5%)	3 (1.5%)
Wound Infection	4 (2%)	3 (1.5%)	1 (.5%)
Hemorrhage	2 (1%)	2 (1%)	0 (0%)
Grade 2	2 (1%)	1 (.5%)	1 (.5%)
Wound Infection (Treated with antibiotics)	2 (1%)	1 (.5%)	1 (.5%)
Grade 3–5	0 (0%)	0 (0%)	0 (0%)
Follow-up (months, median, IQR)	12 (4–22)	11 (5–16)	25 (5–28)	<.001 ^a
Recurrence
No recurrence	176 (99.5%)	122 (69%)	54 (30.5%)	.311^b
Recurrence	1 (.5%)	0 (0%)	1 (.5%)

Significance of bold data–p–values less than 0.05.

Mann–Whitney U-test.

Fisher’s exact test.

IQR, interquartile range; LOS, length of stay.

The median follow-up period of the study group was 12 months (IQR 4–22). While the median follow-up period for patients who underwent telescopic dissection was 11 months (IQR 5–16), it was 25 months (IQR 5–28) for patients in the balloon trocar group, significantly longer than telescopic dissection group (P < .001). Recurrence was observed in only one case in the balloon trocar group during the follow-up period, and there was no significant difference in recurrence rates between the groups (P = .311) (Table 3).

Discussion

Laparoscopic surgery offers advantages compared with open surgery, such as reduced postoperative pain, smaller incisions and fewer wound complications. Numerous publications in the literature have demonstrated that minimally invasive inguinal hernia surgery provides recurrence rates similar to open techniques, as well as less postoperative pain and a reduced incidence of chronic pain.^8,9 TAPP and TEP are two widely used methods in minimally invasive inguinal hernia repair, both have similar outcomes. In a randomized controlled study by Bansal et al.¹⁰ the recurrence and chronic pain rates between the two methods were comparable. However, when evaluating local complications, TEP showed a higher incidence of seromas, while TAPP was associated with increased early postoperative pain and cord edema.

While both techniques require a surgical expertise, the TEP technique involves an additional step of preperitoneal dissection. Adequate preperitoneal dissection is crucial for TEP, and improper execution of this step can lead to various complications and potentially necessitating conversion. Preperitoneal dissection in TEP can be achieved using a laparoscopy camera and blunt instruments or with the balloon trocar.^1–3 In a randomized controlled study conducted by Bringman et al.³ in 2001, these two methods were compared, and it was reported that the balloon dissection technique shortened the operating time and reduced the conversion rate. However, in current studies comparing these two techniques, it is observed that the operation time and conversion rates are similar.^5,11,12 The utilization of balloon trocars significantly raises the expenses of TEP surgery, posing a challenge in countries where covering these costs is problematic. According to the IEHS 2011 guideline, balloon trocars are advised, particularly for procedures conducted by surgeons in their learning phase, with reports indicating that balloon dissection decreases early postoperative pain and seroma formation. Nevertheless, recent studies indicate no significant difference in local complications between these two techniques.^5,11,12 In our study, it is seen that the operation time, conversion rates, postoperative pain scores, length of stay, complication rates and recurrence rates are similar in the telescopic and balloon dissection groups, consistent with the current literature.

The retrospective nature, limited sample size, and longer follow-up period in the balloon dissection group are among the limitations of our study. While our series observed only one recurrence in the balloon dissection group, assessing the impact of technical variations on recurrence is not fully feasible with this study’s outcomes due to the longer follow-up period in the balloon dissection group. Nonetheless, other literature reports indicate no discernible difference in recurrence rates between these two techniques.^3,11,12

Conclusion

Telescopic dissection method can be considered as a suitable, safe and lower-cost alternative to balloon dissection for preperitoneal dissection in inguinal hernia repair with TEP.

Footnotes

Authors’ Contributions

B.D.: Concept; B.D., S.Ö., and İ.E.A.: Design; S.Ö. and İ.E.A.: Supervision; B.D.: Materials; B.D.: Data collection and/or processing; B.D. and S.Ö.: Analysis and/or interpretation; B.D.: Literature search; B.D.: Writing; S.Ö. and İ.E.A.: Critical review. All authors read and approved the final version of article.

Author Disclosure Statement

All authors have no conflict of interest to declare.

Funding Information

All authors declare that there is no funding or financial grants to disclose.

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