JKSS

J Korean Surg Soc 2012;82:40-44

http://dx.doi.org/10.4174/jkss.2012.82.1.40

Journal of the Korean Surgical Society

pISSN 2233-7903eISSN 2093-0488

ORIGINAL ARTICLE

Comparison of the outcomes between laparoscopic

totally extraperitoneal repair and prolene hernia system
for inguinal hernia; review of one surgeons experience
Yoon Young Choi, Sun Wook Han1, Sang Ho Bae1, Sung Yong Kim1, Kyung Yul Hur,
Gil Ho Kang1
Department of Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul,
1
Department of Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan,
Korea

Purpose: To compare the outcomes between laparoscopic total extraperitoneal (TEP) repair and prolene hernia system (PHS)
repair for inguinal hernia. Methods: A retrospective analysis of 237 patients scheduled for laparoscopic TEP or PHS repair of
groin hernia from 2005 to 2009 was performed. Results: The mean age was 52.3 years in TEP group and 55.7 years in PHS
group. Of 119 TEP cases, 98 were indirect inguinal hernia, 15 direct type, 5 femoral hernia and 1 complex hernia; Of 118 PHS
cases, 100 indirect, 18 direct type. All in TEP group were performed under general anesthesia and 64% of PHS group were
performed under spinal or epidural anesthesia. Preoperatively, 10 cases of recurrent inguinal hernia were involved in our
study (4 in TEP, 6 in PHS group). The mean operative time was similar in both groups (74.8 in TEP, 71.2 in PHS group), however mean hospital stay (1.6 days in TEP, 3.2 days in PHS group, P = 0.018) and mean usage of analgesics (0.54 times in TEP,
2.03 times in PHS group, P 0.01), complications (36 cases in TEP, 6 cases in PHS group, P 0.01) showed statistical
differences. There is only 1 case of postoperative recurrence inguinal hernia in PHS group but it has no statistical significance
(P = 0.314). Conclusion: Compared to PHS repair, laparoscopic TEP repair has some advantages; shorter hospital stay, less
frequent need of analgesics; as well as more postoperative complications such as hematoma, seroma, scrotal swelling.
Key Words: Inguinal hernia, Laparoscopy, Surgical mesh

low recurrence rate. These tension-free repair procedures

INTRODUCTION

can be roughly categorized into two groups; laparoscopic

Inguinal hernia repair is one of the most common proce-

and open anterior approach. As laparoscopic hernia re-

dures in field of general surgery. There have been various

pair, total extraperitoneal (TEP) repair, transabdominal

methods for inguinal hernia repair, but recently, so called

preperitoneal (TAPP) repair, and intraperitoneal onlay

tension-free repair is the procedure of choice [1] due to its

mesh (IPOM) repair are well known. Among them, TEP is

Received July 22, 2011, Revised October 25, 2011, Accepted November 7, 2011
Correspondence to: Gil Ho Kang
Department of Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, 31 Soonchunhyang
6-gil, Dongnam-gu, Cheonan 330-721, Korea
Tel: 82-41-507-3637, Fax: 82-41-571-0129, E-mail: khmdgiri@gmail.com
cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright 2012, the Korean Surgical Society

Compare TEP and PHS

accepted as the most ideal method because it can avoid en-

ypropylene; Ethicon Inc., Somerville, MA, USA) was lo-

try into the peritoneal cavity, which can cause intraperi-

cated in the prepared preperitoneal space without any fix-

toneal complication such as bowel injury or obstruction

ation and determined that it was well-located under view.

[2]. And among open tension-free methods, such as

The onlay patch of mesh was located around the spermatic

Lichtensteins operation, repair using mesh plug or pro-

cord and well positioned with some fixation.

lene hernia system (PHS), PHS repair is becoming an accepted and popular technique because of shorter operating time, about 10%, and its low recurrence rate [3,4].

Laparoscopic TEP technique

A laparoscopic TEP repair is performed using a three-

Recently, there are many reports comparing these two

port technique. To create the pre-peritoneal space, a 15 mm

laparoscopic and open tension-free methods [5-7]. How-

skin transverse incision is made at the inferior edge of

ever, there have been few reports comparing laparoscopic

umbilicus. The incision is carried down to the con-

TEP with PHS repair for inguinal hernia. Thus, we de-

tralateral side of the anterior sheath of the rectus abdomi-

signed this study and have reviewed our data.

nis muscle. Then, a small incision is made in the anterior

sheath to expose the rectus abdominis muscle. A channel
between the rectus muscle and the posterior sheath is cre-

METHODS

ated with peanuts in Kelly, so that a small tunnel is made

in the direction to pubis between the rectus abdominis

A retrospective analysis of 237 patients scheduled for

muscle and the peritoneum. Using spacemaker dissection

laparoscopic TEP or PHS repair of unilateral inguinal her-

balloon (Autosuture, Norwlk, CT, USA), the pre-peri-

nia from August 2005 to August 2009 was performed. In

toneal space is developed. Finally, another 5 mm port is

study duration, 15 patients who had bilateral inguinal her-

placed 2 cm superior to symphysis pubis in the midline

nia and 11 patients who had TAPP repair performed, 4 pa-

and another 5 mm port is placed in the middle between the

tients who had IPOM repair performed were excluded

2 existing ports.

from this data. Also, the patients who had shorter than 12

In most direct inguinal hernias, the loosened trans-

months of follow up were excluded. A total of 237 (TEP,

versalis fascia is fixed to Coopers ligament with a 5 mm

119; PHS, 118) patients were involved. Until 2007, we had

spiral tack (Tyco Healthcare, Norwalk, CT, USA) to reduce

mainly performed PHS repair method, but thereafter,

dead space. In indirect inguinal hernias, the sac is com-

have performed laparoscopic TEP repair, except in the fol-

pletely isolated and reducted. In addition, in femoral her-

lowing cases; the anesthesiologist recommended that the

nias, the sac is completely reducted. A 15 10 cm polyester

patient was not suitable for general anesthesia, the patient

mesh (Parietex, sofradim, Trevoux, France) is placed and

didnt want TEP repair due to cost. All operations were

anchored with 5 mm spiral tacks (Tyco Healthcare); the

performed by a single surgeon. Outcome was compared in

mesh is fixed in Coopers ligament routinely, and, occa-

demographics and perioperative details with post-

sionally, there are additional fixations.

operative data.

Data collection
Open PHS technique

The operative time was recorded from skin incision to

In all procedures, we opened the inguinal canal under

skin closure. Hematoma was defined as presence of ecchy-

oblique incision and the hernia sac was identified and iso-

mosis on operative site. Scrotal swelling was included on-

lated from spermatic cord. In indirect type, the sac re-

ly when the patient complained during follow-up, and se-

ducted to the peritoneal cavity without ligation. In direct

roma was defined as the case in which the aspirated fluid

type, after reducting the sac without ligation the preper-

was over 5 mL. Sustained pain was defined if operative site

itoneal space was made digitally in a blunt manner.

pain was sustained 3 months after surgery. The length of

Underlay patch of mesh (PHS, monofilament knitted pol-

hospital stay was defined as the total number of nights

thesurgery.or.kr

41

Yoon Young Choi, et al.

spent in the hospital after surgery. Recurrence after oper-

82%, and there were 5 cases of femoral hernia and 1 case of

ation was diagnosed upon physical examination. The pa-

pantaloon hernia in TEP group only. All TEP group sur-

tients were followed up in the outpatient hernia clinic de-

geries were performed under general anesthesia. But 34%

partment regularly. Some patients were followed up by

of cases in PHS group were performed under general an-

phone call; but if not available by phone, the last follow up

esthesia, and other cases under spinal or epidural

findings were used for data. Patients who had shorter than

anesthesia. Preoperatively, 10 cases of recurrent hernia

12 months of follow up were excluded from our data.

were involved in our study (4 in TEP, 6 in PHS group).

Peri-operative data is shown in Table 2. The mean operation time in TEP and PHS group was 74.8 36.5 (range, 30

Statistical analysis
Chi-square test was used for analysis of independency

to 290) and 71.2 33.2 minutes (range, 25 to 225 minutes)

of data in both group, and the mean data was compared by

respectively; it was similar between the two groups. The

independent t-test. Data collected in the database were an-

hospital stay in TEP and PHS groups were 1.6 1.5 (range,

alyzed using SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA).

1 to 11) and 3.2 6.9 days (range, 1 to 15 days), respectively;

A P-value less than 0.05 was considered as significant.

shorter in TEP than in PHS group (P = 0.018). The times of

analgesics usage were 0.5 0.5 (range, 0 to 1) and 2.0 2.8
(range, 0 to 21); less use in TEP than in PHS group (P
0.01). However, postoperative complications more fre-

RESULTS

quently occurred in TEP (36 cases, 30.3%) than in PHS (6

As Table 1 shows, the mean follow up duration was 32

cases, 5.1%) group (P 0.01). Only one recurrence was de-

months (range, 13 to 58 months). The mean age of TEP

tected during follow up period in PHS group, but it did

group was 52.3 19.5 (range, 15 to 87) and 55.7 17.7 years
(range, 17 to 90 years) in PHS group. The male to female
sex ratio of the 237 patients was 112:7 in TEP group and

Table 2. Postoperative outcomes between TEP and PHS

TEP (n = 119)

PHS (n = 118)

Operative time (min) 74.79 36.49

Hospital stay (day)
1.61 1.54
Analgesics (time)
0.54 0.50
Complication
36 (30.3)
Recurrence
0 (0)

71.19 33.17
3.16 6.86
2.03 2.75
6 (5.1)
1 (0.8)

107:11 in PHS group. One hundred and forty-seven cases

were right side inguinal hernia (TEP, 7 1; PHS, 76) and 90
cases were left side (TEP, 48; PHS, 42). Indirect types were

Table 1. Demographics between TEP group and PHS group

Variable

TEP (n = 119)

PHS (n = 118)

Age (yr)
52.29 19.52
55.69 17.71
Sex
112 (94) / 7 (6)
107 (91) / 11 (9)
(male/female)
Location
48 (40.3) / 71 (59.7) 42 (35.6) / 76 (64.4)
(left/right)
Hernia type
Direct
15 (12.6)
18 (15.3)
Indirect
98 (82.4)
100 (84.7)
Femoral
5 (4.2)
0 (0)
Pantaloon
1 (0.8)
0 (0)
Recurrent
4 (3.3)
6 (5.1)
Anesthesia
General
119 (100)
40 (33.9)
Spinal
0 (0)
73 (61.9)
Epidural
0 (0)
5 (4.2)
Values are presented as mean SD or number (%).
TEP, total extraperitoneal; PHS, prolene hernia system.

42

P-value

P-value
0.427
0.018
0.01
0.01
0.314

Values are presented as mean SD or number (%).

TEP, total extraperitoneal; PHS, prolene hernia system.

0.162
0.318
0.452

Table 3. Details of postoperative complication between TEP and

PHS
TEP (n = 119) PHS (n = 118)

0.098

0.539
0.00

Operative site
hematoma
Scrotal swelling
Seroma
150 mL
50-150 mL
50 mL
Wound infection
Sustained pain

P-value

20 (16.8)

2 (1.7)

0.01

7 (5.9)
9 (7.6)
2 (1.7)
2 (1.7)
5 (4.2)
0 (0)
0 (0)

0 (0)
1 (0.8)
0 (0)
0 (0)
1 (0.8)
1 (0.8)
2 (1.7)

0.01
0.010

0.498
0.247

Values are presented as number (%).

TEP, total extraperitoneal; PHS, prolene hernia system.

thesurgery.or.kr

Compare TEP and PHS

not show any statistical significance.

Variation of the operative time can be influenced by the

Table 3 describes the details of postoperative complica-

operator or author (his or her operative style, habit, ten-

tion in each group. The operative site hematoma was de-

dency). In our data, all operations were performed by a

tected in 20 cases (16.8%), scrotal swelling in 7 cases (5.9%)

single surgeon, so, we could say there was no difference in

and seroma in 9 cases (7.6%) of TEP group. On the other

the operative time between laparoscopic hernia repair and

hand, there were only 2 hematoma and 1 seroma in PHS

open hernia repair.

group. Therefore, the hematoma, swelling and seroma

Hospital stay was shorter in TEP group (1.6 days) than

were more frequently detected in TEP than in PHS group

PHS group (3.1 days). Other authors have reported that

(P 0.01, P 0.01, P = 0.010, respectively). No patient suf-

TEP repair results in a quicker return to normal functional

fered from sustained pain in TEP group, but 2 patients suf-

status [15], and an improved quality-of-life outcome [16].

fered in PHS group (P = 0.247). There were no other serious

However, hospital stay was not decided by only patients

complications in either group.

physical condition but surgeons preference, secondary

gain such as private insurance, the hospitals turn over rate
of sickbed, psychological effect, and traditional beliefs.

DISCUSSION

The amount of postoperative intravenous or intramuscular analgesics use was lower in TEP group (0.54

Bassinis procedure [8] was standard procedure for re-

times) than PHS group (2.03 times). Recently, Blinman [17]

pair of inguinal hernia until tension-free hernia repair pro-

reported very interesting results; even though the sum of

cedure using mesh was introduced by Lichtenstein and

incision is same, the total tensions are not equal, so con-

Shulman [9]. The tension-free hernia repair method was

ventional incisions are subject to more total tension than

developed and now there are various methods such as

combination of trocar incisions. In this point of view, our

plane mesh, plug mesh, PHS repair, and laparoscopic TEP,

result is understandable. And even breakup of incision

TAPP, IPOM repair. Of these, the PHS repair was in-

may have cosmetic effects.

troduced by Gilbert et al. [4] in 1999, and has become a

There were no serious complications in both groups.

popular procedure because it is easy to perform when; the

However, minor complications were detected more fre-

anatomy is not clear [10], there is decreased operating time

quently in TEP group (36 cases, 30.3%) than PHS group (6

[3], low recurrent rate [4], and/or it could prevent femoral

cases, 5.1%). Operative site hematoma was the most com-

hernia [10]. And laparoscopic TEP repair has been consid-

mon complication (16.8%) after TEP repair, but subsided

ered as the laparoscopic procedure of choice for inguinal

spontaneously without any intervention or medication.

hernia [11] because of the following; high recurrence rate

Although operative site hematoma was a minor complica-

after IPOM [12], TEP can avoid entry into the peritoneal

tion, since laparoscopic operation should be considered as

cavity [2], the incidence of serious complications is lower

a cosmetic standpoint, careful dissection of preperitoneal

after TEP than TAPP [11].

space, and delicate bleeding control might be required to

We have compared these two popular procedures for

prevent it. Postoperative scrotal swelling occurred in 7 cas-

inguinal hernia; there was no difference in demographic

es of TEP repair; they were resolved without any inter-

features between the two groups. All TEP repairs and 34%

vention. On the other hand, a total of 10 cases of seroma

of PHS repairs were performed under general anesthesia,

were detected (9 cases of TEP, 1 case of PHS) and aspiration

but no postoperative complication related to general or

was done; after that there was no recurrence of seroma.

spinal anesthesia was observed.

There have been reports about the risk factors of seroma

Many authors have reported that the operating time for

formation after laparoscopic TEP [18,19]: large hernia de-

laparoscopic hernia repair procedure could be longer than

fects, scrotal extension of the hernia, potential cavity exists

open [13,14], and in some [7] it was the same. In our results,

between the mesh and the transversalis fascia, male gen-

the operative time was similar between the two groups.

der, and indirect type.

thesurgery.or.kr

43

Yoon Young Choi, et al.

The present study came from a single surgeons results,

so there may be bias; this result cannot be adopted by all
surgeons. However, a single surgeons results has a strong
point; coherent standards were applied to postoperative
outcomes such as operative time, hospital stay, and
amount of analgesics.
In conclusion, laparoscopic TEP repair and PHS hernia
repair had acceptably low recurrence rates and similar operating times. The advantage of TEP repair was shorter
hospital stay, lower analgesics use, and cosmetic effect.
However, the TEP repair had more minor postoperative
complications than those of PHS repair.

CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article
was reported.

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thesurgery.or.kr