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A systematic review comparing single-incision versus multi-incision laparoscopic surgery for inguinal hernia repair with mesh
International Journal of Surgery 29 (2016) 25e35
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International Journal of Surgery journal homepage: www.journal-surgery.net
Review
A systematic review comparing single-incision versus multi-incision laparoscopic surgery for inguinal hernia repair with mesh* M.S. Sajid a, *, A.H. Khawaja a, M. Sayegh b, M.K. Baig a a
Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex, BN11 2DH, UK b Department of General, Upper Gastrointestinal & Hepato-pancreatico-biliary Surgery, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital Worthing, West Sussex, BN11 2DH, UK
h i g h l i g h t s Single incision laparoscopic inguinal (SILS) hernia repair has several advantages such as better cosmesis and reduced pain score and analgesics requirements. This study presents meta-analysis of fifteen comparative studies on 1651 patients undergoing SILS versus conventional multi-incision laparoscopic (MILS) inguinal hernia repair. The recovery time was significantly quicker in SILS compared to MILS group However, the statistical equivalence was seen in outcomes of length of hospital stay, operative time both for unilateral and bilateral hernias, postoperative pain score, one-week pain score, recurrence, conversion [odds ratio, and post-operative complications. Both SILS and MILS approaches of laparoscopic inguinal hernia repair are feasible, safe and can be offered to patients depending upon the availability of expertise and resources.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 November 2015 Received in revised form 19 February 2016 Accepted 20 February 2016 Available online 11 March 2016
Objective: The objective of this article is to evaluate whether the surgical outcomes differ between single incision laparoscopic surgery (SILS) versus multi-incision laparoscopic surgery (MILS) for the repair of inguinal hernia. Methods: A systematic review of the literature on published studies reporting the surgical outcomes following SILS versus MILS for inguinal hernia repair was undertaken using the principles of meta-analysis. Results: Fifteen comparative studies on 1651 patients evaluating the surgical outcomes in patients undergoing SILS versus MILS for inguinal hernia repair were systematically analysed. The post-operative recovery time was significantly quicker [odds ratio, 0.35 (CI, 0.57 e 0.14), p ¼ 0.001] following SILS compared to MILS procedure. However, the statistical equivalence was seen in outcomes of length of hospital stay, operative time both for unilateral and bilateral hernias, post-operative pain score, oneweek pain score, hernia recurrence [odds ratio, 1.24 (CI, 0.47e3.23), p ¼ 0.66], conversion [odds ratio, 1.07 (CI, 0.37e3.12), p ¼ 0.90], and post-operative complications [odds ratio, 0.95 (CI, 0.66e1.36, p ¼ 0.78] between two approaches. The sub-group analysis of four included randomized, controlled trials showed similarities between outcomes following SILS and MILS except slightly higher postoperative pain score in MILS group. Conclusions: Both SILS and MILS approaches of inguinal hernia repair are feasible, safe and can be offered to patients depending upon the availability of expertise and resources. © 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
Keywords: Inguinal hernia Laparoscopic hernia repair Single incision repair Multi-incision repair
* The provisional abstract of this study has been presented as an oral paper at the International Surgical Congress of the Associations of Surgeons of Great Britain and Ireland (ASGBI) from 22nde24th April 2015 in Manchester, United Kingdom. Published citation Br J Surg 2015; 102(102): 43. * Corresponding author. Worthing Hospital, Washington Suite, North Wing, West Sussex, BN11 2DH, UK. E-mail address: [email protected] (M.S. Sajid).
http://dx.doi.org/10.1016/j.ijsu.2016.02.088 1743-9191/© 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
1. Introduction Inguinal hernia is one of the most common general surgical condition comprising 7% of all surgical outpatient visits [1]; its repair being the most common general surgical procedure with
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over 20 million of inguinal hernia repairs performed worldwide every year [2,3]. A lifetime risk of developing inguinal hernia is estimated to be 27% for men and 3% for women [4]. Various techniques have been used to repair inguinal hernia since the first comprehensive technique described by Bassini in 1887 [5]. At present three techniques remains the mainstay of repair of inguinal hernia. a) Shouldice repair which is the primary repair of hernia with surgical suture and it is almost obsolete in clinical practice except in emergency situations, b) Open “tension free” mesh repair technique pioneered by Lichtenstein in 1984 which is still considered the method of choice for primary inguinal hernia and c) the laparoscopic mesh placement, which is considered a gold standard treatment for recurrent and bilateral hernias [6e8]. The laparoscopic repair of inguinal hernia by either total extra-peritoneal (TEP) approach or trans-abdominal pre-peritoneal (TAPP) approach has gained immense popularity in last two decades owing to its advantages of less postoperative pain, quicker recovery time, better cosmetic results and the opportunity to examine the contralateral side [9e15] in addition to its role in the management of bilateral and recurrent hernias [13]. Conventional laparoscopic inguinal hernia (TEP or TAPP) repair usually requires three ports sized 5 mme10 mm and a total skin incision length analogous with that of an open repair. Efforts were being made to lessen the post-operative pain and improve cosmetic result produced as a result of surgical trauma resulting from the incisions required. Consequently, this led to the emergence of
single-incision laparoscopic surgery (SILS); the first case of SILS-TEP was performed in 2008 by FilipoviceCugura [16]. There have been number of studies and case reports discussing its feasibility and safety [17e24] in the medical literature. Good clinical outcomes in terms of lesser requirements of analgesia and superior cosmesis [25,26] following SILS approach for laparoscopic repair of inguinal hernia is rapidly taking over the multi-incision laparoscopic surgery (MILS). The aim of this systematic review is thus to compare the outcome of SILS and MILS for inguinal hernia repair in published randomized, non-randomized and comparative studies. 2. Methods To find relevant articles for this review, a search of electronic databases such as PubMed, Medline, EMBASE and the Cochrane Library was conducted using the standard medical subject headings (MeSH) without the limits for language, gender, sample size and the place of study. The references of the published articles were hand searched to find additional studies that may have been missed by the literature search. The data of all types of comparative trials (randomized, non-randomized) was collected and analysed systematically to achieve a combined outcome for the purpose of generation of a conclusive evidence. The statistical analysis of the extracted data was conducted according to the guidelines provided by the Cochrane Collaboration including the use of RevMan 5.3® statistical software, random-effects model analysis, heterogeneity
Fig. 1. PRISMA flow chart.
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Table 1 Characteristics of included trials. Study de Araujo et al. [35] SILS MILS Bharathi et al. [36] SILS MILS Bialecki et al. [37] SILS MILS Buckley et al. [38] SILS MILS Cugura et al. [39] SILS MILS Kim et al. [40] SILS MILS Sato et al. [41] SILS MILS Sherwinter et al. [42] SILS MILS Tai et al. [43] SILS MILS Tran et al. [44] SILS MILS Tsai et al. [45] SILS MILS Uchida et al. [46] SILS MILS Wakasugi et al. [47] SILS MILS Wijerathne et al. [48] SILS MILS Yang et al. [49] SILS MILS
Year
Country
Patients
Age in years
Male: Female Not reported
50
56.5 ± 3.51 57.7 ± 3.29
163
5 (1e14) 5 (1.5e14)
98:4 45:6
61
60 (26e77)
35:0 26:0
205
55.57 ± 7.9 55 ± 18.24
119:10 71:5
Study design Retrospective matched pair group analysis
Brazil/USA 2014
Retrospective cohort study 2008
India
Prospective controlled clinical trial 2014
Poland
Retrospective study 2014
USA
Randomized controlled trial 2012
Croatia
58.5 (20e84) 55.0 (17e79)
44:0
59.9 ± 13.2 59.5 ± 13.5
72:4 87:6
64.3 61.0
28:7 45:5
104
37.5 ± 11.9 33.7 ± 11.3
46:6 50:2
139
46.9 ± 13.6 56.4 ± 14
48:6 81:4
100
48 (18) 54 (24)
Not reported
100
55.4 ± 15.1 53.2 ± 17.2
44: 6 45: 5
177
51.1 ± 35 57.9 ± 35.5
31:29 50:67
137
65 ± 12 61 ± 14
87:13 34: 3
50
46 (±11) 45 (±12)
26: 0 24: 0
67
61.7 (28e88) 61.5 (38e81)
29:3 32:3
44
Retrospective analysis of prospectively collected data South Korea 2013
169
Prospective, controlled clinical trial 2012
Japan
85
Retrospective analysis of prospectively collected data 2010
USA
Retrospective analysis of prospectively collected data Taiwan/USA 2011
Randomized, controlled trial 2014
Australia
Randomized, controlled trial Taiwan/USA 2013
Retrospective analysis of prospectively collected data 2010
Japan
Retrospective analysis 2015
Japan
Randomized trial 2014
Singapore
Retrospective analysis of prospectively collected data 2015
China
testing by chi-squared test, heterogeneity quantification by Isquared test and the use of forest plots for the graphical display of the combined outcomes [27e31]. The methodological quality of the included randomized trials was initially assessed using the published guidelines of Jadad et al. and Chalmers et al. [32,33]. The short summary of the resulting evidence was presented in a tabulated form by using GradePro® [34] tool, provided by the Cochrane Collaboration.
3. Results 3.1. Study selection Fifteen comparative studies (4 randomized controlled trials, 2 non-randomized, controlled trials and 9 retrospective studies) were considered suitable for the pooled analysis [35e49]. The PRISMA flow chart to explain the literature search strategy and trial selection is given in Fig. 1. The characteristics of included trials are given in Table 1. In total 1651 patients evaluating the surgical outcomes in patients undergoing SILS versus MILS for inguinal hernia were systematically analysed. There were 860 patients in the SILS
group and 791 patients in the MILS group. Two trials were conducted on paediatric patients [36,46] and the remaining thirteen [35,37e45,47e49] studies were carried out on adult patients. Eleven studies [35,36,38e40,42e45,47,48] compared patients undergoing total extra peritoneal (TEP) repair; two studies [36,46] reported laparoscopic percutaneous extra-peritoneal approach on paediatric patients and two studies [41,49] were conducted using both the TEP and the TAP approaches for inguinal hernia repair. 3.2. Risk of bias assessment in included studies The tabulated summary of resulting evidence is given in Fig. 2. Table 2 shows the quality indicator of included randomized, controlled trials. 3.3. Combined analysis of all studies 3.3.1. Duration of operation for unilateral inguinal hernia repair As shown in Fig. 3a, ten studies reported the duration of operation for unilateral inguinal hernia repair [35,36,38,41e44,46,47]. In the random effects model analysis (SMD, 0.07; 95% CI, 0.38,
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Fig. 2. GradePro summary of evidence.
Table 2 Reported RCT quality indicators. Study
Randomization
Power calculations
ITT
Blinding
Concealment
Jadad score
Cugura et al. [39] Tran et al. [44] Tsai et al. [45] Wijerathne et al. [48]
Yes Yes Yes Yes
Yes Yes Yes Yes
No Yes Yes Not reported
No Yes No Yes
Not Reported Yes Yes Yes
3 4 4 4
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Fig. 3. a- Forest plot for duration of operation of unilateral inguinal hernia by SILS versus MILS. Standardized mean difference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for duration of operation of bilateral inguinal hernia by SILS versus MILS. Standardized mean difference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for length of hospital stay in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
0.23; z ¼ 0.48; P ¼ 0.63), the duration of operation for unilateral hernia repair was statistically similar in both SILS and MILS groups. There was significant heterogeneity (Tau2 ¼ 0.17, c2 ¼ 34.80, df ¼ 9, [P < 0.0001]; I2 ¼ 74%) among included studies.
3.3.2. Duration of operation for bilateral hernia repair As shown in Fig. 3b, ten studies reported the duration of operation for bilateral inguinal hernia repair [35,36,38,39,41e44,46,47]. In the random effects model analysis (SMD, 0.02; 95% CI, 0.40,
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Fig. 4. a- Forest plot for pain score on post op 1st day in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for pain score on post op one week in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for conversion of cases in SILS versus MILS of inguinal hernia. Odds ratio is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
0.44; z ¼ 0.09; P ¼ 0.93), the duration of operation for bilateral hernia repair was also statistically similar following SILS and MILS procedures. There was significant heterogeneity (Tau2 ¼ 0.24, c2 ¼ 24.92, df ¼ 9, [P ¼ 0.003]; I2 ¼ 64%) among included studies. 3.3.3. Length of hospital stay As shown in Fig. 3c, eight studies [35,39e41,43,45,47,48] contributed to the combined calculation of this variable. In the
random effects model analysis (SMD, 0.04; 95% CI, 0.32, 0.24; z ¼ 0.29; P ¼ 0.77), the length of hospitalization was also found statistically similar in both groups. There was significant heterogeneity (Tau2 ¼ 0.07, c2 ¼ 12.82, df ¼ 5 [P ¼ 0.03]; I2 ¼ 61%) among included studies. 3.3.4. Day 1 post-operative pain score As shown in Fig. 4a, six studies reported the pain score on the
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Fig. 5. a- Forest plot for complications in SILS versus MILS of inguinal hernia. Odds Ratio is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multiincision laparoscopic surgery. b- Forest plot for recurrent cases after SILS versus MILS of inguinal hernia. Odds ratio is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for recovery time for patients after SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
first post-operative day [37,40,43e45,48]. In the random effects model analysis (SMD, 0.14; 95% CI, 0.41, 0.13; z ¼ 1.03; P ¼ 0.30), the pain score after 24 h of the surgery was statistically similar in both SILS and MILS groups. There was significant heterogeneity (Tau2 ¼ 0.07, c2 ¼ 13.18, df ¼ 5, [P ¼ 0.02]; I2 ¼ 62%) among included studies.
3.3.5. Day 7 post-operative pain score As shown in Fig. 4b, six studies reported the pain score on day 7 [37,40,43e45,48]. In the random effects model analysis (SMD, 0.27; 95% CI, 0.56, 0.01; z ¼ 1.89; P ¼ 0.06), the pain score was statistically similar in both groups. There was significant heterogeneity (Tau [2] ¼ 0.08, c2 ¼ 14.75, df ¼ 5, [P ¼ 0.01]; I2 ¼ 66%] among included studies.
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Fig. 6. a- Forest plot for operating time for hernia in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for length of hospital stay in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for pain score on post-op 1st day in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
3.3.6. Laparoscopic to open conversion rate As shown in Fig. 4c, ten studies reported conversion of the procedure [35,36,38,40,41,44,45,47e49] to open hernia repair. In the random effects model analysis (OR, 1.07; 95% CI, 0.37, 3.12; z ¼ 0.13; P ¼ 0.90), the conversions rate was similar in both groups. There was no heterogeneity (Tau2 ¼ 0.00, c2 ¼ 1.35, df ¼ 4, [P ¼ 0.85]; I2 ¼ 0%) among included studies. 3.3.7. Post-operative complications As shown in Fig. 5a, twelve studies reported the post-operative complications [35e38,40e43,45,47e49]. In the random effects model analysis (OR, 0.95; 95% CI, 0.66, 1.36; z ¼ 0.28; P ¼ 0.78), the post-operative complication rate was also similar in MILS and SILs groups. There was no heterogeneity (Tau2 ¼ 0.00, c2 ¼ 4.51, df ¼ 11, [P ¼ 0.95]; I2 ¼ 0%) among included studies. 3.3.8. Recurrence of hernia As shown in Fig. 5b, thirteen studies reported the recurrence of inguinal hernia [35-39,41,43-49.] In the random effects model analysis (OR, 1.24; 95% CI, 0.47, 3.23; z ¼ 0.44; P ¼ 0.66), the risk of recurrent hernia was similar in both groups. There was no heterogeneity (Tau2 ¼ 0.00, c2 ¼ 3.26, df ¼ 6, [P ¼ 0.78]; I2 ¼ 0%) among included studies.
3.3.9. Post-operative recovery time As shown in Fig. 5c, four studies [35,42e44] contributed to the combined calculation of this variable. In the random effects model analysis (SMD, 0.35; 95% CI, 0.57, 0.14; z ¼ 3.19; P ¼ 0.001), the recovery time was faster following SILS compared to MILS. There was no heterogeneity (Tau2 ¼ 0.01; c2 ¼ 3.41, df ¼ 3 [P ¼ 0.33]; I2 ¼ 12%) among included studies. 3.4. Subgroup analysis of four randomized trials only 3.4.1. Duration of operation As shown in Fig. 6a, the combined analysis of three randomized, controlled trials [44,45,48], the random effects model analysis (SMD, 0.31; 95% CI, 0.30, 0.92; z ¼ 0.99; P ¼ 0.32) showed that the duration of operation for hernia repair was statistically similar in SILS and MILS groups. However, there was significant heterogeneity (Tau2 ¼ 0.24, c2 ¼ 11.11, df ¼ 2, [P ¼ 0.004]; I2 ¼ 82%) among included randomized studies. 3.4.2. Length of hospital stay As shown in Fig. 6b, hospital stay was reported by three randomized trials [39,45,48]. In the random effects model analysis (SMD, 0.05; 95% CI, 0.79, 0.89; z ¼ 0.13; P ¼ 0.90), no statistical difference was found among both the groups.
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Fig. 7. a- Forest plot for pain score on post-op 1st week in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for complications in RCT's in SILS versus MILS of inguinal hernia. Odds ratio is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
3.4.3. Day 1 pain score As shown in Fig. 6c, pain score on first post-operative day was reported by three randomized trials [44,45,48]. In the random effects model analysis (SMD 0.43; 95% CI 0.71, 0.16; z ¼ 3.09; p ¼ 0.002), the day 1 pain score was significantly lower in SILS group. 3.4.4. Day 7 pain score As shown in Fig. 7a, the day 7 pain score was reported in three randomized, controlled trials [44,45,48] which was statistically similar (SMD, 0.24; 95% CI, 0.72, 0.23; z ¼ 1.00; P ¼ 0.32) in both groups. 3.4.5. Post-operative complications As shown in Fig. 7b, all causes post-operative morbidity was reported in two included randomized, controlled trials [45,48] which showed similar risks in both groups of laparoscopic inguinal hernia repair. 4. Discussion Laparoscopic surgery since its advent in early 1990's is increasingly being preferred by the surgeons and patients worldwide due to its overall benefits evident by operative results and patient satisfaction [50]. With almost similar results to open mesh repair, laparoscopy provides an alternative to inguinal hernia repair especially in bilateral or recurrent cases [51]. Single incision surgery is a step forward to enhance the same advantages as reducing the number of surgical incisions, may potentially lessens the analgesia requirement and potential sites where post-operative infection may occur. However, technical challenges posed by the procedure are responsible for a longer learning curve for surgeons. The conventional concepts of necessary triangulation in laparoscopic surgery and limited operative field space are impending reasons for prolonged duration of the operation and unique iatrogenic injuries. Despite showing promising results, the SILS approach for inguinal hernia has failed to demonstrate a clinically proven advantage over
the MILS approach and based upon the findings of current study statistical equivalence may be extrapolated.
4.1. Limitations This systematic review is a combined analysis of randomized and non-randomized, controlled trials with variable inclusion and exclusion criteria of patient recruitment. Furthermore, the approaches of TEP and TAPP were adopted at surgeon's choice and the availability of resources. Therefore, the combined outcomes may not be considered free from bias. Diverse inclusion and exclusion criteria, variable pain measuring tools in included trials and dissimilar duration of follow up may well be responsible for clinical, methodological and statistical heterogeneity among included studies. Similarly, inconsistencies in the types and size of laparoscopic ports used, use of different types of mesh and experience of the operating surgeons pose an added bias to the outcomes of this study. A high quality, multi-centre randomized, controlled trial is thus required to validate the findings of this study prior to the recommendation of the routine use of SILS for inguinal hernia repair.
5. Conclusion This systematic review shows the safety of SILS and its efficacy in the management of inguinal hernia repair but its statistical equivalence to MILS fails to approve its routine use. No statistical difference as compared to MILS in operating time, post-operative complications and recurrence rates of hernia may make this technique be more conveniently adopted by surgeons in future if training and resources are available. Despite showing promising results, SILS approach for inguinal hernia has failed to demonstrate a measureable clinically proven advantage over MILS approach and based upon the findings of current study statistical equivalence may be extrapolated.
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Conflict of interest None to declare. Financial support None to declare. Sources of funding None to declare. Ethical approval Not applicable. Author contribution Mr MS Sajid: Study idea, literature search, trial selection, data extraction and analysis and article writing. AH Khawaja: Data extraction, trial selection, article proof reading. Mr M Sayegh: Data confirmation, Data interpretation, article proof reading. Mr MK Baig … Data confirmation, data interpretation, proof reading. Guarantor Mr MS SAJID. References [1] Inguinal Hernias. [Accessed 10th June 2015] Available http://www.patient.co. uk/doctor/inguinal. (hernias). [2] H. Kulacoglu, Current options in inguinal hernia repair in adult patients, Hippokratia 15 (2011) 223e231. [3] R.1 Bittner, J. Schwarz, Inguinal hernia repair: current surgical techniques, Langenbecks Arch. Surg. 397 (2012) 271e282. [4] P. Primatesta, M.J. Goldcare, Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality, Int. J. Epidemiol. 25 (1996) 835e839. [5] Bassini, Nuevo Metodo per la Cure Radicale Dell'ernia Inguinale, Prosperini, Padua, 1889. [6] E.E. Shouldice, The treatment of hernia, Med. Rev. 1 (1953) 1e14. [7] I.L. Lichtenstein, A.G. Shulman, P.K. Amid, M.M. Montllor, The tension-free hernioplasty, Am. J. Surg. 157 (1989) 188e193. [8] S.A. Antoniou, R. Pointner, F.A. Granderath, Current treatment concepts for groin hernia, Langenbecks Arch. Surg. 399 (2014) 553e558. [9] R. Ger, K. Monroe, R. Duvivier, et al., Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac, Am. J. Surg. 159 (1990) 370e373. [10] K. McCormack, N.W. Scott, P.M. Go, et al., AM. EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair, Cochrane Database Syst. Rev. 1 (2003) CD001785. [11] S. Olmi, A. Scaini, G.C. Cesana, et al., Laparoscopic versus open incisional hernia repair: an open randomized controlled study, Surg. Endosc. 21 (2007) 555e559. [12] Pawanindra Lal, P. Philips, J. Chander, et al., Is unilateral laparoscopic TEP inguinal hernia repair a job half done? The case for bilateral repair, Surg. Endosc. 24 (2010) 1737e1745. [13] D. Mahon, B. Decadt, M. Rhodes, Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia, Surg. Endosc. 17 (2003) 1386e1390. €ger, B. Kraft, et al., Laparoscopic hernia repaireTAPP or/and TEP? [14] B.J. Leibl, C. Ja Langenbecks Arch. Surg. 390 (2005) 77e82. [15] K. McCormack, B.L. Wake, C. Fraser, et al., Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review, Hernia 9 (2005) 109e114. [16] J. Filipovic-Cugura, I. Kirac, T. Kulis, et al., Single-incision laparoscopic surgery (SILS) for totally extraperitoneal (TEP) inguinal hernia repair: first case, Surg. Endosc. 23 (2009) 920e921. [17] W. Pesta, W. Kurpiewski, M. Luba, et al., Single incision laparoscopic surgery transabdominal pre-peritoneal hernia repair - case report, Wideochir Inne Tech. Malo Inwazyjne 7 (2012) 137e139.
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Arora, et al., Laparoscopic ligation of internal ringthree ports versus single-port technique: are working ports necessary? J. Laparoendosc. Adv. Surg. Tech. 18 (2008) 891e894. [37] J.T. Białecki, M.M. Wieloch, K. Kołomecki, Single incision approach to totally extraperitoneal inguinal hernia repair, Wideochir Inne Tech. Malo Inwazyjne 9 (2014) 201e206. [38] F.P. Buckley 3rd, H. Vassaur, S. Monsivais, et al., Comparison of outcomes for single-incision laparoscopic inguinal herniorrhaphy and traditional three-port laparoscopic herniorrhaphy at a single institution, Surg. Endosc. 28 (2014) 30e35. [39] J.F. Cugura, I. Kirac, T. Kulis, et al., Comparison of single incision laparoscopic totally extraperitoneal and laparoscopic totally extraperitoneal inguinal hernia repair: initial experience, J. Endourol. 26 (2012) 63e66. [40] J.H. Kim, Y.S. Lee, J.J. Kim, et al., Single port laparoscopic totally extraperitoneal hernioplasty: a comparative study of short-term outcome with conventional laparoscopic totally extraperitoneal hernioplasty, World J. Surg. 37 (2013) 746e751. [41] H. Sato, M. Shimada, N. Kurita, et al., The safety and usefulness of the single incision, transabdominal pre-peritoneal (TAPP) laparoscopic technique for inguinal hernia, J. Med. Invest. 59 (2012) 235e240. [42] D.A. Sherwinter, Transitioning to single-incision laparoscopic inguinal herniorrhaphy, JSLS 14 (2010) 353e357. [43] H.C. Tai, C.D. Lin, S.D. Chung, et al., A comparative study of standard versus Laparoendoscopic single-site surgery (LESS) totally extraperitoneal (TEP) inguinal hernia repair, Surg. Endosc. 25 (2011) 2879e2883. [44] H. Tran, I. Turingan, K. Tran, et al., Potential benefits of single-port compared to multiport laparoscopic inguinal herniorraphy: a prospective randomized controlled study, Hernia 18 (2014) 731e744. [45] Y.C. Tsai, C.H. Ho, H.C. Tai, et al., Laparoendoscopic single-site versus conventional laparoscopic total extraperitoneal hernia repair: a prospective randomized clinical trial, Surg. Endosc. 27 (2013) 4684e4692. [46] H. Uchida, H. Kawashima, C. Goto, et al., Inguinal hernia repair in children using single-incision laparoscopic-assisted percutaneous extraperitoneal closure, J. Pediatr. Surg. 45 (2010) 2386e2389. [47] M. Wakasugi, T. Masuzawa, M. Tei, et al., Single-incision totally extraperitoneal inguinal hernia repair: our initial 100 cases and comparison with conventional three-port laparoscopic totally extraperitoneal inguinal hernia repair, Surg. Today 45 (2015) 606e610. [48] S. Wijerathne, N. Agarwal, A. Ramzy, et al., A prospective randomized controlled trial to compare single-port endo-laparoscopic surgery versus
M.S. Sajid et al. / International Journal of Surgery 29 (2016) 25e35 conventional TEP inguinal hernia repair, Surg. Endosc. 28 (2014) 3053e3058. [49] G.P. Yang, K.L. Tung, A comparative study of single incision versus conventional laparoscopic inguinal hernia repair, Hernia 19 (2015) 401e405. [50] A. Rao, J. Kynaston, E.R. MacDonald, et al., Patient preferences for surgical
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techniques: Should we invest in new approaches? Surg. Endosc. 24 (2010) 3016e3025. [51] X. Feliu, R. Claveria, P. Besora, et al., Bilateral inguinal hernia repair: Laparoscopic or open approach? Hernia 15 (2011) 15e18.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Review
A systematic review comparing single-incision versus multi-incision laparoscopic surgery for inguinal hernia repair with mesh* M.S. Sajid a, *, A.H. Khawaja a, M. Sayegh b, M.K. Baig a a
Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex, BN11 2DH, UK b Department of General, Upper Gastrointestinal & Hepato-pancreatico-biliary Surgery, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital Worthing, West Sussex, BN11 2DH, UK
h i g h l i g h t s Single incision laparoscopic inguinal (SILS) hernia repair has several advantages such as better cosmesis and reduced pain score and analgesics requirements. This study presents meta-analysis of fifteen comparative studies on 1651 patients undergoing SILS versus conventional multi-incision laparoscopic (MILS) inguinal hernia repair. The recovery time was significantly quicker in SILS compared to MILS group However, the statistical equivalence was seen in outcomes of length of hospital stay, operative time both for unilateral and bilateral hernias, postoperative pain score, one-week pain score, recurrence, conversion [odds ratio, and post-operative complications. Both SILS and MILS approaches of laparoscopic inguinal hernia repair are feasible, safe and can be offered to patients depending upon the availability of expertise and resources.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 November 2015 Received in revised form 19 February 2016 Accepted 20 February 2016 Available online 11 March 2016
Objective: The objective of this article is to evaluate whether the surgical outcomes differ between single incision laparoscopic surgery (SILS) versus multi-incision laparoscopic surgery (MILS) for the repair of inguinal hernia. Methods: A systematic review of the literature on published studies reporting the surgical outcomes following SILS versus MILS for inguinal hernia repair was undertaken using the principles of meta-analysis. Results: Fifteen comparative studies on 1651 patients evaluating the surgical outcomes in patients undergoing SILS versus MILS for inguinal hernia repair were systematically analysed. The post-operative recovery time was significantly quicker [odds ratio, 0.35 (CI, 0.57 e 0.14), p ¼ 0.001] following SILS compared to MILS procedure. However, the statistical equivalence was seen in outcomes of length of hospital stay, operative time both for unilateral and bilateral hernias, post-operative pain score, oneweek pain score, hernia recurrence [odds ratio, 1.24 (CI, 0.47e3.23), p ¼ 0.66], conversion [odds ratio, 1.07 (CI, 0.37e3.12), p ¼ 0.90], and post-operative complications [odds ratio, 0.95 (CI, 0.66e1.36, p ¼ 0.78] between two approaches. The sub-group analysis of four included randomized, controlled trials showed similarities between outcomes following SILS and MILS except slightly higher postoperative pain score in MILS group. Conclusions: Both SILS and MILS approaches of inguinal hernia repair are feasible, safe and can be offered to patients depending upon the availability of expertise and resources. © 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
Keywords: Inguinal hernia Laparoscopic hernia repair Single incision repair Multi-incision repair
* The provisional abstract of this study has been presented as an oral paper at the International Surgical Congress of the Associations of Surgeons of Great Britain and Ireland (ASGBI) from 22nde24th April 2015 in Manchester, United Kingdom. Published citation Br J Surg 2015; 102(102): 43. * Corresponding author. Worthing Hospital, Washington Suite, North Wing, West Sussex, BN11 2DH, UK. E-mail address: [email protected] (M.S. Sajid).
http://dx.doi.org/10.1016/j.ijsu.2016.02.088 1743-9191/© 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
1. Introduction Inguinal hernia is one of the most common general surgical condition comprising 7% of all surgical outpatient visits [1]; its repair being the most common general surgical procedure with
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over 20 million of inguinal hernia repairs performed worldwide every year [2,3]. A lifetime risk of developing inguinal hernia is estimated to be 27% for men and 3% for women [4]. Various techniques have been used to repair inguinal hernia since the first comprehensive technique described by Bassini in 1887 [5]. At present three techniques remains the mainstay of repair of inguinal hernia. a) Shouldice repair which is the primary repair of hernia with surgical suture and it is almost obsolete in clinical practice except in emergency situations, b) Open “tension free” mesh repair technique pioneered by Lichtenstein in 1984 which is still considered the method of choice for primary inguinal hernia and c) the laparoscopic mesh placement, which is considered a gold standard treatment for recurrent and bilateral hernias [6e8]. The laparoscopic repair of inguinal hernia by either total extra-peritoneal (TEP) approach or trans-abdominal pre-peritoneal (TAPP) approach has gained immense popularity in last two decades owing to its advantages of less postoperative pain, quicker recovery time, better cosmetic results and the opportunity to examine the contralateral side [9e15] in addition to its role in the management of bilateral and recurrent hernias [13]. Conventional laparoscopic inguinal hernia (TEP or TAPP) repair usually requires three ports sized 5 mme10 mm and a total skin incision length analogous with that of an open repair. Efforts were being made to lessen the post-operative pain and improve cosmetic result produced as a result of surgical trauma resulting from the incisions required. Consequently, this led to the emergence of
single-incision laparoscopic surgery (SILS); the first case of SILS-TEP was performed in 2008 by FilipoviceCugura [16]. There have been number of studies and case reports discussing its feasibility and safety [17e24] in the medical literature. Good clinical outcomes in terms of lesser requirements of analgesia and superior cosmesis [25,26] following SILS approach for laparoscopic repair of inguinal hernia is rapidly taking over the multi-incision laparoscopic surgery (MILS). The aim of this systematic review is thus to compare the outcome of SILS and MILS for inguinal hernia repair in published randomized, non-randomized and comparative studies. 2. Methods To find relevant articles for this review, a search of electronic databases such as PubMed, Medline, EMBASE and the Cochrane Library was conducted using the standard medical subject headings (MeSH) without the limits for language, gender, sample size and the place of study. The references of the published articles were hand searched to find additional studies that may have been missed by the literature search. The data of all types of comparative trials (randomized, non-randomized) was collected and analysed systematically to achieve a combined outcome for the purpose of generation of a conclusive evidence. The statistical analysis of the extracted data was conducted according to the guidelines provided by the Cochrane Collaboration including the use of RevMan 5.3® statistical software, random-effects model analysis, heterogeneity
Fig. 1. PRISMA flow chart.
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Table 1 Characteristics of included trials. Study de Araujo et al. [35] SILS MILS Bharathi et al. [36] SILS MILS Bialecki et al. [37] SILS MILS Buckley et al. [38] SILS MILS Cugura et al. [39] SILS MILS Kim et al. [40] SILS MILS Sato et al. [41] SILS MILS Sherwinter et al. [42] SILS MILS Tai et al. [43] SILS MILS Tran et al. [44] SILS MILS Tsai et al. [45] SILS MILS Uchida et al. [46] SILS MILS Wakasugi et al. [47] SILS MILS Wijerathne et al. [48] SILS MILS Yang et al. [49] SILS MILS
Year
Country
Patients
Age in years
Male: Female Not reported
50
56.5 ± 3.51 57.7 ± 3.29
163
5 (1e14) 5 (1.5e14)
98:4 45:6
61
60 (26e77)
35:0 26:0
205
55.57 ± 7.9 55 ± 18.24
119:10 71:5
Study design Retrospective matched pair group analysis
Brazil/USA 2014
Retrospective cohort study 2008
India
Prospective controlled clinical trial 2014
Poland
Retrospective study 2014
USA
Randomized controlled trial 2012
Croatia
58.5 (20e84) 55.0 (17e79)
44:0
59.9 ± 13.2 59.5 ± 13.5
72:4 87:6
64.3 61.0
28:7 45:5
104
37.5 ± 11.9 33.7 ± 11.3
46:6 50:2
139
46.9 ± 13.6 56.4 ± 14
48:6 81:4
100
48 (18) 54 (24)
Not reported
100
55.4 ± 15.1 53.2 ± 17.2
44: 6 45: 5
177
51.1 ± 35 57.9 ± 35.5
31:29 50:67
137
65 ± 12 61 ± 14
87:13 34: 3
50
46 (±11) 45 (±12)
26: 0 24: 0
67
61.7 (28e88) 61.5 (38e81)
29:3 32:3
44
Retrospective analysis of prospectively collected data South Korea 2013
169
Prospective, controlled clinical trial 2012
Japan
85
Retrospective analysis of prospectively collected data 2010
USA
Retrospective analysis of prospectively collected data Taiwan/USA 2011
Randomized, controlled trial 2014
Australia
Randomized, controlled trial Taiwan/USA 2013
Retrospective analysis of prospectively collected data 2010
Japan
Retrospective analysis 2015
Japan
Randomized trial 2014
Singapore
Retrospective analysis of prospectively collected data 2015
China
testing by chi-squared test, heterogeneity quantification by Isquared test and the use of forest plots for the graphical display of the combined outcomes [27e31]. The methodological quality of the included randomized trials was initially assessed using the published guidelines of Jadad et al. and Chalmers et al. [32,33]. The short summary of the resulting evidence was presented in a tabulated form by using GradePro® [34] tool, provided by the Cochrane Collaboration.
3. Results 3.1. Study selection Fifteen comparative studies (4 randomized controlled trials, 2 non-randomized, controlled trials and 9 retrospective studies) were considered suitable for the pooled analysis [35e49]. The PRISMA flow chart to explain the literature search strategy and trial selection is given in Fig. 1. The characteristics of included trials are given in Table 1. In total 1651 patients evaluating the surgical outcomes in patients undergoing SILS versus MILS for inguinal hernia were systematically analysed. There were 860 patients in the SILS
group and 791 patients in the MILS group. Two trials were conducted on paediatric patients [36,46] and the remaining thirteen [35,37e45,47e49] studies were carried out on adult patients. Eleven studies [35,36,38e40,42e45,47,48] compared patients undergoing total extra peritoneal (TEP) repair; two studies [36,46] reported laparoscopic percutaneous extra-peritoneal approach on paediatric patients and two studies [41,49] were conducted using both the TEP and the TAP approaches for inguinal hernia repair. 3.2. Risk of bias assessment in included studies The tabulated summary of resulting evidence is given in Fig. 2. Table 2 shows the quality indicator of included randomized, controlled trials. 3.3. Combined analysis of all studies 3.3.1. Duration of operation for unilateral inguinal hernia repair As shown in Fig. 3a, ten studies reported the duration of operation for unilateral inguinal hernia repair [35,36,38,41e44,46,47]. In the random effects model analysis (SMD, 0.07; 95% CI, 0.38,
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Fig. 2. GradePro summary of evidence.
Table 2 Reported RCT quality indicators. Study
Randomization
Power calculations
ITT
Blinding
Concealment
Jadad score
Cugura et al. [39] Tran et al. [44] Tsai et al. [45] Wijerathne et al. [48]
Yes Yes Yes Yes
Yes Yes Yes Yes
No Yes Yes Not reported
No Yes No Yes
Not Reported Yes Yes Yes
3 4 4 4
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Fig. 3. a- Forest plot for duration of operation of unilateral inguinal hernia by SILS versus MILS. Standardized mean difference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for duration of operation of bilateral inguinal hernia by SILS versus MILS. Standardized mean difference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for length of hospital stay in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
0.23; z ¼ 0.48; P ¼ 0.63), the duration of operation for unilateral hernia repair was statistically similar in both SILS and MILS groups. There was significant heterogeneity (Tau2 ¼ 0.17, c2 ¼ 34.80, df ¼ 9, [P < 0.0001]; I2 ¼ 74%) among included studies.
3.3.2. Duration of operation for bilateral hernia repair As shown in Fig. 3b, ten studies reported the duration of operation for bilateral inguinal hernia repair [35,36,38,39,41e44,46,47]. In the random effects model analysis (SMD, 0.02; 95% CI, 0.40,
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Fig. 4. a- Forest plot for pain score on post op 1st day in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for pain score on post op one week in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for conversion of cases in SILS versus MILS of inguinal hernia. Odds ratio is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
0.44; z ¼ 0.09; P ¼ 0.93), the duration of operation for bilateral hernia repair was also statistically similar following SILS and MILS procedures. There was significant heterogeneity (Tau2 ¼ 0.24, c2 ¼ 24.92, df ¼ 9, [P ¼ 0.003]; I2 ¼ 64%) among included studies. 3.3.3. Length of hospital stay As shown in Fig. 3c, eight studies [35,39e41,43,45,47,48] contributed to the combined calculation of this variable. In the
random effects model analysis (SMD, 0.04; 95% CI, 0.32, 0.24; z ¼ 0.29; P ¼ 0.77), the length of hospitalization was also found statistically similar in both groups. There was significant heterogeneity (Tau2 ¼ 0.07, c2 ¼ 12.82, df ¼ 5 [P ¼ 0.03]; I2 ¼ 61%) among included studies. 3.3.4. Day 1 post-operative pain score As shown in Fig. 4a, six studies reported the pain score on the
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Fig. 5. a- Forest plot for complications in SILS versus MILS of inguinal hernia. Odds Ratio is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multiincision laparoscopic surgery. b- Forest plot for recurrent cases after SILS versus MILS of inguinal hernia. Odds ratio is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for recovery time for patients after SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
first post-operative day [37,40,43e45,48]. In the random effects model analysis (SMD, 0.14; 95% CI, 0.41, 0.13; z ¼ 1.03; P ¼ 0.30), the pain score after 24 h of the surgery was statistically similar in both SILS and MILS groups. There was significant heterogeneity (Tau2 ¼ 0.07, c2 ¼ 13.18, df ¼ 5, [P ¼ 0.02]; I2 ¼ 62%) among included studies.
3.3.5. Day 7 post-operative pain score As shown in Fig. 4b, six studies reported the pain score on day 7 [37,40,43e45,48]. In the random effects model analysis (SMD, 0.27; 95% CI, 0.56, 0.01; z ¼ 1.89; P ¼ 0.06), the pain score was statistically similar in both groups. There was significant heterogeneity (Tau [2] ¼ 0.08, c2 ¼ 14.75, df ¼ 5, [P ¼ 0.01]; I2 ¼ 66%] among included studies.
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Fig. 6. a- Forest plot for operating time for hernia in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for length of hospital stay in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for pain score on post-op 1st day in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
3.3.6. Laparoscopic to open conversion rate As shown in Fig. 4c, ten studies reported conversion of the procedure [35,36,38,40,41,44,45,47e49] to open hernia repair. In the random effects model analysis (OR, 1.07; 95% CI, 0.37, 3.12; z ¼ 0.13; P ¼ 0.90), the conversions rate was similar in both groups. There was no heterogeneity (Tau2 ¼ 0.00, c2 ¼ 1.35, df ¼ 4, [P ¼ 0.85]; I2 ¼ 0%) among included studies. 3.3.7. Post-operative complications As shown in Fig. 5a, twelve studies reported the post-operative complications [35e38,40e43,45,47e49]. In the random effects model analysis (OR, 0.95; 95% CI, 0.66, 1.36; z ¼ 0.28; P ¼ 0.78), the post-operative complication rate was also similar in MILS and SILs groups. There was no heterogeneity (Tau2 ¼ 0.00, c2 ¼ 4.51, df ¼ 11, [P ¼ 0.95]; I2 ¼ 0%) among included studies. 3.3.8. Recurrence of hernia As shown in Fig. 5b, thirteen studies reported the recurrence of inguinal hernia [35-39,41,43-49.] In the random effects model analysis (OR, 1.24; 95% CI, 0.47, 3.23; z ¼ 0.44; P ¼ 0.66), the risk of recurrent hernia was similar in both groups. There was no heterogeneity (Tau2 ¼ 0.00, c2 ¼ 3.26, df ¼ 6, [P ¼ 0.78]; I2 ¼ 0%) among included studies.
3.3.9. Post-operative recovery time As shown in Fig. 5c, four studies [35,42e44] contributed to the combined calculation of this variable. In the random effects model analysis (SMD, 0.35; 95% CI, 0.57, 0.14; z ¼ 3.19; P ¼ 0.001), the recovery time was faster following SILS compared to MILS. There was no heterogeneity (Tau2 ¼ 0.01; c2 ¼ 3.41, df ¼ 3 [P ¼ 0.33]; I2 ¼ 12%) among included studies. 3.4. Subgroup analysis of four randomized trials only 3.4.1. Duration of operation As shown in Fig. 6a, the combined analysis of three randomized, controlled trials [44,45,48], the random effects model analysis (SMD, 0.31; 95% CI, 0.30, 0.92; z ¼ 0.99; P ¼ 0.32) showed that the duration of operation for hernia repair was statistically similar in SILS and MILS groups. However, there was significant heterogeneity (Tau2 ¼ 0.24, c2 ¼ 11.11, df ¼ 2, [P ¼ 0.004]; I2 ¼ 82%) among included randomized studies. 3.4.2. Length of hospital stay As shown in Fig. 6b, hospital stay was reported by three randomized trials [39,45,48]. In the random effects model analysis (SMD, 0.05; 95% CI, 0.79, 0.89; z ¼ 0.13; P ¼ 0.90), no statistical difference was found among both the groups.
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Fig. 7. a- Forest plot for pain score on post-op 1st week in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for complications in RCT's in SILS versus MILS of inguinal hernia. Odds ratio is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
3.4.3. Day 1 pain score As shown in Fig. 6c, pain score on first post-operative day was reported by three randomized trials [44,45,48]. In the random effects model analysis (SMD 0.43; 95% CI 0.71, 0.16; z ¼ 3.09; p ¼ 0.002), the day 1 pain score was significantly lower in SILS group. 3.4.4. Day 7 pain score As shown in Fig. 7a, the day 7 pain score was reported in three randomized, controlled trials [44,45,48] which was statistically similar (SMD, 0.24; 95% CI, 0.72, 0.23; z ¼ 1.00; P ¼ 0.32) in both groups. 3.4.5. Post-operative complications As shown in Fig. 7b, all causes post-operative morbidity was reported in two included randomized, controlled trials [45,48] which showed similar risks in both groups of laparoscopic inguinal hernia repair. 4. Discussion Laparoscopic surgery since its advent in early 1990's is increasingly being preferred by the surgeons and patients worldwide due to its overall benefits evident by operative results and patient satisfaction [50]. With almost similar results to open mesh repair, laparoscopy provides an alternative to inguinal hernia repair especially in bilateral or recurrent cases [51]. Single incision surgery is a step forward to enhance the same advantages as reducing the number of surgical incisions, may potentially lessens the analgesia requirement and potential sites where post-operative infection may occur. However, technical challenges posed by the procedure are responsible for a longer learning curve for surgeons. The conventional concepts of necessary triangulation in laparoscopic surgery and limited operative field space are impending reasons for prolonged duration of the operation and unique iatrogenic injuries. Despite showing promising results, the SILS approach for inguinal hernia has failed to demonstrate a clinically proven advantage over
the MILS approach and based upon the findings of current study statistical equivalence may be extrapolated.
4.1. Limitations This systematic review is a combined analysis of randomized and non-randomized, controlled trials with variable inclusion and exclusion criteria of patient recruitment. Furthermore, the approaches of TEP and TAPP were adopted at surgeon's choice and the availability of resources. Therefore, the combined outcomes may not be considered free from bias. Diverse inclusion and exclusion criteria, variable pain measuring tools in included trials and dissimilar duration of follow up may well be responsible for clinical, methodological and statistical heterogeneity among included studies. Similarly, inconsistencies in the types and size of laparoscopic ports used, use of different types of mesh and experience of the operating surgeons pose an added bias to the outcomes of this study. A high quality, multi-centre randomized, controlled trial is thus required to validate the findings of this study prior to the recommendation of the routine use of SILS for inguinal hernia repair.
5. Conclusion This systematic review shows the safety of SILS and its efficacy in the management of inguinal hernia repair but its statistical equivalence to MILS fails to approve its routine use. No statistical difference as compared to MILS in operating time, post-operative complications and recurrence rates of hernia may make this technique be more conveniently adopted by surgeons in future if training and resources are available. Despite showing promising results, SILS approach for inguinal hernia has failed to demonstrate a measureable clinically proven advantage over MILS approach and based upon the findings of current study statistical equivalence may be extrapolated.
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Conflict of interest None to declare. Financial support None to declare. Sources of funding None to declare. Ethical approval Not applicable. Author contribution Mr MS Sajid: Study idea, literature search, trial selection, data extraction and analysis and article writing. AH Khawaja: Data extraction, trial selection, article proof reading. Mr M Sayegh: Data confirmation, Data interpretation, article proof reading. Mr MK Baig … Data confirmation, data interpretation, proof reading. Guarantor Mr MS SAJID. References [1] Inguinal Hernias. [Accessed 10th June 2015] Available http://www.patient.co. uk/doctor/inguinal. (hernias). [2] H. Kulacoglu, Current options in inguinal hernia repair in adult patients, Hippokratia 15 (2011) 223e231. [3] R.1 Bittner, J. Schwarz, Inguinal hernia repair: current surgical techniques, Langenbecks Arch. Surg. 397 (2012) 271e282. [4] P. Primatesta, M.J. Goldcare, Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality, Int. J. Epidemiol. 25 (1996) 835e839. [5] Bassini, Nuevo Metodo per la Cure Radicale Dell'ernia Inguinale, Prosperini, Padua, 1889. [6] E.E. Shouldice, The treatment of hernia, Med. Rev. 1 (1953) 1e14. [7] I.L. Lichtenstein, A.G. Shulman, P.K. Amid, M.M. Montllor, The tension-free hernioplasty, Am. J. Surg. 157 (1989) 188e193. [8] S.A. Antoniou, R. Pointner, F.A. Granderath, Current treatment concepts for groin hernia, Langenbecks Arch. Surg. 399 (2014) 553e558. [9] R. Ger, K. Monroe, R. Duvivier, et al., Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac, Am. J. Surg. 159 (1990) 370e373. [10] K. McCormack, N.W. Scott, P.M. Go, et al., AM. EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair, Cochrane Database Syst. Rev. 1 (2003) CD001785. [11] S. Olmi, A. Scaini, G.C. Cesana, et al., Laparoscopic versus open incisional hernia repair: an open randomized controlled study, Surg. Endosc. 21 (2007) 555e559. [12] Pawanindra Lal, P. Philips, J. Chander, et al., Is unilateral laparoscopic TEP inguinal hernia repair a job half done? The case for bilateral repair, Surg. Endosc. 24 (2010) 1737e1745. [13] D. Mahon, B. Decadt, M. Rhodes, Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia, Surg. Endosc. 17 (2003) 1386e1390. €ger, B. Kraft, et al., Laparoscopic hernia repaireTAPP or/and TEP? [14] B.J. Leibl, C. Ja Langenbecks Arch. Surg. 390 (2005) 77e82. [15] K. McCormack, B.L. Wake, C. Fraser, et al., Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review, Hernia 9 (2005) 109e114. [16] J. Filipovic-Cugura, I. Kirac, T. Kulis, et al., Single-incision laparoscopic surgery (SILS) for totally extraperitoneal (TEP) inguinal hernia repair: first case, Surg. Endosc. 23 (2009) 920e921. [17] W. Pesta, W. Kurpiewski, M. Luba, et al., Single incision laparoscopic surgery transabdominal pre-peritoneal hernia repair - case report, Wideochir Inne Tech. Malo Inwazyjne 7 (2012) 137e139.
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