Improved patient-reported outcomes after open preperitoneal inguinal hernia repair compared to anterior Lichtenstein repair: 10-year ACHQC analysis

Abstract

Introduction: The Lichtenstein repair has been synonymous with "open" inguinal hernia repair (IHR) for 40 years. However, international guidelines have suggested that posterior mesh placement results in advantageous biomechanics and reduced risk of nerve-related chronic pain. Additionally, the use of local anesthetics has been shown to reduce postoperative pain and complication risks. An open transrectus preperitoneal/open preperitoneal (TREPP/OPP) repair combines posterior mesh placement with the use of local anesthetic and as such could be the ideal repair for primary inguinal hernia. Using the Abdominal Core Health Quality Collaborative (ACHQC) registry, we compared open anterior mesh with open posterior mesh repairs.

Methods: We performed a propensity score matched analysis of patients undergoing open IHR between 2012 and 2022 in the ACHQC. After 1:1 optimal matching, both the TREPP/OPP and Lichtenstein cohorts were balanced with 451 participants in each group. Outcomes included patient-reported quality of life (QoL), hernia recurrence, and postoperative opioid use.

Results: Improvement was seen after TREPP/OPP in EuraHS QoL score at 30 days (OR 0.558 [0.408, 0.761]; p = 0.001), and the difference persisted at 1 year (OR 0.588 [0.346, 0.994]; p = 0.047). Patient-reported opioid use at 30-day follow-up was significantly lower in the TREPP/OPP cohort (OR 0.31 [0.20, 0.48]; p < 0.001). 30-day frequency of surgical-site occurrences was significantly higher in the Lichtenstein repair cohort (OR 0.22 [0.06-0.61]; p = 0.007). There were no statistically significant differences in hernia recurrence risk at 1 year, or rates of postoperative bleeding, peripheral nerve injury, DVTs, or UTIs.

Conclusion: Our analysis demonstrates a benefit of posterior mesh placement (TREPP/OPP) over anterior mesh placement (Lichtenstein) in open inguinal hernia repair in patient-reported QoL and reduced opioid use.

Keywords: Inguinal hernia; Lichtenstein; Preperitoneal repair; Quality-of-life; TREPP/OPP.

Fig. 1

Incision is approximately 4 cm long, and 2/3rd medial to the midpoint between ASIS and the pubic tubercle

Fig. 2

The external oblique has been opened, and the iliohypogastric nerve is typically seen along the internal oblique and rectus sheath

Fig. 3

The internal obliques are separated at the lateral edge of the rectus sheath, typically above the iliohypogastric nerve

Fig. 4

The aponeurosis of the transversus abdominis, which are sometimes fused with the transversalis fascia, must be divided to gain access to the preperitoneal plane

Fig. 5

Care must be taken to identify and to protect the inferior epigastric vessels, by feeling or seeing them, and then retracting them medially with the rectus which is superficial. Blunt finger dissection can then be used to create a preperitoneal pocket, similar to a balloon dissector in a TEP or laparoscopic instruments in a TAPP. The peritoneum is rarely ever entered

Fig. 6

Dissection of the peritoneal sac and preperitoneal fat is straightforward as the peritoneum is immediately accessed, and is superficial to the spermatic vessels. A high ligation is performed for a large inguinal or scrotal hernia

Fig. 7

a Surgeons view looking down toward the pelvis demonstrating the anterior abdominal wall structures. Confirmation of peritoneal dissection is done by observing the course of the vas into the deep pelvis. This view is aided using a surgical headlight. b The medial dissection is performed with minimal electrocautery as this is an avascular plane. Dissection is concluded when the pubic symphysis is cleared and tissue is cleared 2 cm below and deep to the pubic bone. The iliac vein is clearly seen in all but the morbidly obese patients

Fig. 8

a The mesh is inserted and placed carefully covering the entire myopectineal orifice of Fruchaud, and the peritoneum is pulled up to ensure no movement or curling of the mesh. b The anterior portion of the mesh is flipped down to cover the peritoneum and the bladder. It is then sutured to the Cooper’s ligament under direct visualization

Fig. 9

The internal obliques are allowed to come together naturally over the mesh to avoid suturing near the iliohypogastric nerve

Fig. 10

The external oblique aponeurosis is closed with a running absorbable suture, taking care not to entrap the iliohypogastric nerve