Page 23 - International guidelines for groin hernia management

Hernia

Evidence in literature employed overly small meshes (\ 10 9 15 cm) or mesh
Out of hundreds of articles that were identified in the of different size for TAPP and TEP. 219, 221, 223–226, 229
search 42 (including 2 abstracts) were analyzed. Out of Finally, follow-up duration differed for the TAPP and
these eight were systematic reviews. 199–206 and three were TEP groups (24–42.5 vs 9–28.8 months). 210, 211, 215–218,
large registry studies. 207–209 226, 227, 233, 235, 236
Analyses of the RCTs and of the comparative non-
randomized studies showed many types of bias. A Operation time, recurrence rate, pain, costs, access-
variety of confounding factors potentially impacting related complications and conversion
results were not mentioned or accounted for and were
not identified by multivariate analyses. Most of the Due to the heterogeneity and weaknesses of the TAPP vs
randomized studies lacked statistical power. 210–215 The TEP studies, results varied greatly. The most recently
numbers of patients per intervention group were inad- published meta-analysis of ten RCTs failed to show any
equate resulting in the risk of a type II error. 210, 211, significant differences in operative times, total complica-
215–217
Methods of patient allocation to one of the two tion rates, hospital length of stay, recovery time, pain,
techniques were not clearly stated. 213, 218, 219 Surgeon’s recurrence rates or costs between TAPP and TEP. 222
levels of experience with both techniques were not Operation time
studied. In five of the studies, surgeons started laparo- In 22 comparisons,TAPP operative timesvaried from 34.5 to
scopic hernia repair with TAPP, then, after gaining 104.5 min (median of 57 min) and TEP operative times
experience, switched to TEP. Thus the level of expe- varied from 32.5 to 110 min (median of
rience in laparoscopic surgery was not equivalent at the 62.3 min). 207, 209–214, 216, 217, 219, 223–226, 229, 231, 232, 234–238
220–224
study’s beginning. The cited high early recur- Complication rates
rence rates ([ 25%) and long operative times strongly In 24 comparisons, TAPP complication rates ranged from
suggest that the studied surgeons had not yet completed 1.23 to 49% (median of 11.4%) and TEP complication rates
the learning curve. 210, 211, 217, 219, 221, 223–225 Technical ranged from 1.3 to 50.3% (median 12.5%). 207, 209–214,
216–219, 221, 222, 224–227, 229, 231–237, 239
details such as mesh and fixation types, which could One registry study
influence postoperative pain and/or recurrence, were reported a lower complication rate for TAPP, 207 while
omitted. 67, 210–213, 216, 218, 226–234 Some of the studies another for TEP. 209

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