Routine TEP technique requires three skin incisions for placement of three trocars in the midline. Otherwise, this can be done by three-port triangular technique or two-hand technique. This study reports a randomised trial of perioperative outcomes and ergonomics characteristics of this procedure using two different techniques of port insertion.
N = 28 patients were randomised into two groups for triangular three-port (TTEP) versus midline three-port TEP (MTEP) hernioplasty after informed written consent in Department of Surgery, King George’s Medical University UP between September 2016 and September 2017 after institutional ethical approval. Patient-related outcomes in terms of quality of life (QOL) and ergonomic evaluation of the technique were compared in double-blinded fashion.
Postoperative pain score at 24 h post surgery (5.1 ± 0.6; 95% CI 4.9–5.3 vs. 4.8 ± 0.4; 95% CI 4.6–4.9) differed, while hospital stay, time to return to routine work, tolerance to oral feeds and intraoperative complications occurrence (OR 2.1; 95% CI 0.2–24.3) were comparable in both groups. Time to return to office work (5.5 ± 0.5; 95% CI 5.4–5.7 vs. 4.0 ± 0.8; 95% CI 3.7–4.3) and immediate postoperative sensation of mesh and pain score were significantly higher in MTEP compared to TTEP. Ergonomic parameters including visualization of landmark score, spreading of mesh score and total surgeon satisfaction score (TTEP 8.4 ± 0.7; 95% CI 8.1–8.6 vs. MTEP 7.0 ± 0.8; 95% CI 6.7–7.3), mental effort quotient (SMEQ score: TTEP 50.6 ± 12.7; 95% CI 45.9–55.3 vs. MTEP 70.8 ± 12.6: 95% CI 66.1–75.4) and physical effort quotient (LEDQ scores in wrist, hand, arm and shoulders) were also superior in triangular technique of port placement.
Triangular three-port TEP hernioplasty is ergonomically feasible and enables a surgeon to perform surgery safely using basic principles of laparoscopy.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Schultz L, Graber J, Pietrafitta J, Hickok D (1990) Laser laparoscopic herniorraphy: a clinical trial preliminary results. J Laparoendosc Surg 1(1):41–45. https://doi.org/10.1089/lps.1990.1.41
Blamey SL, Wale RJ (1991) Laparoscopic repair of inguinal hernia. Med J Aust 155(10):718
Lichtenstein IL, Shulman AG, Amid PK (1991) Laparoscopic hernioplasty. Arch Surg 126(12):1449. https://doi.org/10.1001/archsurg.1991.01410360019002
Kumar A, Agrahari A, Pahwa HS, Anand A, Singh S, Kushwaha JK, Sonkar AA (2017) A prospective non randomized study of comparison of perioperative and quality of life outcomes of endoscopic versus open inguinal hernia repair: data from a developing country. J Laparoendosc Adv Surg Tech A 27(3):264–267. https://doi.org/10.1089/lap.2016.0491
Cho BJ, Jeong WJ, Lee IK, Lee SC (2016) Single-port versus conventional three-port laparoscopic totally extraperitoneal inguinal hernia repair: a randomized controlled trial. Hernia 20(6):789–795. https://doi.org/10.1007/s10029-016-1499-1
Rajapandian S, Senthilnathan P, Gupta A, Gupta PD, Praveenraj P, Vaitheeswaran V, Palanivelu C (2010) Laparoscopic totally extraperitoneal repair of inguinal hernia using two-hand approach—a gold standard alternative to open repair. J Indian Med Assoc 108(10):652–654
Chung SD, Huang CY, Wang SM, Hung SF, Tsai YC, Chueh SC, Yu HJ (2011) Laparoendoscopic single-site totally extraperitoneal adult inguinal hernia repair: initial 100 patients. Surg Endosc 25(11):3579–3583. https://doi.org/10.1007/s00464-011-1761-7
Van der Schatte Olivier RH, Van’t Hullenaar CD, Ruurda JP, Broeders IA (2009) Ergonomics, user comfort, and performance in standard and robot-assisted laparoscopic surgery. Surg Endosc. 23(6):1365–1371. https://doi.org/10.1007/s00464-008-0184-6
Hasbahceci M, Basak F, Acar A, Alimoglu O (2014) A new proposal for learning curve of TEP inguinal hernia repair: ability to complete operation endoscopically as a first phase of learning curve. Minim Invasive Surg 2014:528517. https://doi.org/10.1155/2014/528517
Choi YY, Kim Z, Hur KY (2012) Learning curve for laparoscopic totally extraperitoneal repair of inguinal hernia. Can J Surg 55(1):33–36. https://doi.org/10.1503/cjs.019610
Köckerling F, Bittner R, Kuthe A, Hukauf M, Mayer F, Fortelny R, Schug-Pass C (2017) TEP or TAPP for recurrent inguinal hernia repair-register-based comparison of the outcome. Surg Endosc 31(10):3872–3882. https://doi.org/10.1007/s00464-017-5416-1
Kumar A, Pal AK, Choudhary A, Anand A, Sonkar AA, Pahwa HS (2019) Transfascial suture versus tack fixation of mesh in totally extraperitoneal repair of inguinal hernia: a prospective comparative study. J Minim Access Surg. https://doi.org/10.4103/jmas.JMAS_192_18
Koch CA, Greenlee SM, Larson DR, Harrington JR, Farley DR (2006) Randomized prospective study of totally extraperitoneal inguinal hernia repair: fixation versus no fixation of mesh. JSLS 10(4):457–460
Reiner MA, Bresnahan ER (2016) Laparoscopic total extraperitoneal hernia repair outcomes. JSLS 20(3):e2016.00043. https://doi.org/10.4293/JSLS.2016.00043
Zhu X, Liu Z, Shen J, Tang R (2019) Triangle trocar configuration in laparoscopic totally extraperitoneal inguinal hernia repair: a prospective randomized controlled study. J Surg Res 239:149–155. https://doi.org/10.1016/j.jss.2019.01.067
Kushwaha JK, Enny LE, Anand A, Sonkar AA, Kumar A, Pahwa HS (2017) A prospective randomized controlled trial comparing quality of life following endoscopic totally extraperitoneal (TEP) versus open stoppa inguinal hernioplasty. Surg Laparosc Endosc Percutan Tech 27(4):257–261. https://doi.org/10.1097/SLE.0000000000000450
Heniford BT, Walters AL, Lincourt AE, Novitsky YW, Hope WW, Kercher KW (2008) Comparison of generic versus specific quality-of-life scales for mesh hernia repairs. J Am Coll Surg 206(4):638–644. https://doi.org/10.1016/j.jamcollsurg.2007.11.025
Christoffersen MW, Rosenberg J, Jorgensen LN, Bytzer P, Bisgaard T (2014) Health-related quality of life scores changes significantly within the first three months after hernia mesh repair. World J Surg 38(7):1852–1859. https://doi.org/10.1007/s00268-013-2411-0
Lau H, Patil NG, Yuen WK, Lee F (2002) Learning curve for unilateral endoscopic totally extraperitoneal (TEP) inguinal hernioplasty. Surg Endosc 16(12):1724–1728. https://doi.org/10.1007/s00464-001-8298-0
Schouten N, Simmermacher RK, Van Dalen T, Smakman N, Clevers GJ, Davids PH, Verleisdonk EJ, Burgmans JP (2013) Is there an end of the “learning curve” of endoscopic totally extraperitoneal (TEP) hernia repair? Surg Endosc 27(3):789–794. https://doi.org/10.1007/s00464-012-2512-0
Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant AM (2005) Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database Syst Rev 25(1):CD004703. https://doi.org/10.1002/14651858.CD004703.pub2
Nothing to disclose.
Dr SS and Dr AA have shared co-first authorship of this paper since both have worked equally in conceptualising the study, methodology, data analysis and interpretation. Dr AA has additionally been one of the surgeons in the operative team and has primarily prepared this manuscript. None of the author has any financial conflicts of interest to disclose.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Appendix A: Ergonomics evaluation
Surgeon’s satisfaction score = A + B
Appendix B: Intraoperative findings
About this article
Cite this article
Singh, S., Anand, A., Kumar, A. et al. A prospective randomised control trial to compare the perioperative outcomes and ergonomic challenges between triangular versus midline port placement in total extra-peritoneal repair of uncomplicated unilateral inguinal hernia. Surg Endosc 35, 1395–1404 (2021). https://doi.org/10.1007/s00464-020-07525-4
- TEP hernioplasty
- Port placement