Laparoscopic repair of both sided inguinal hernia by entering the abdominal cavity vs not entering the abdominal cavity

Completed

• Conditions: Bilateral Inguinal hernia

• Registration Number: CTRI/2015/01/005377
• Lead Sponsor: Lady Hardinge Medical College

Brief Summary

**PROJECT PROTOCOL**

**Randomized trial comparing laparoscopictransabdominal preperitoneal (TAPP) and laparoscopic totally extra peritoneal(TEP) approach for bilateral inguinal hernia.**

**Name of Institution                                       :**  Departmentof Surgery

LadyHardinge Medical College,

NewDelhi-110001

**Nameof Principal Investigator                    :**  Dr.Deborshi Sharma

**Signatureof Investigator                              :**

    **INTRODUCTION**

 Inguinalhernia as an entity was introduced as early as 1500 B.C. Hernia is derived from the Latin wordfor “ruptureâ€, and is defined as an abnormal protrusion of an organ or tissuethrough a defect in its surrounding walls. Hernias are a common problem;however, their true incidence is unknown. Hernia can occur at various sites ofthe body, mostly involve the abdominal wall and particularly the inguinalregion. Hernias mostly occur at sites where the aponeurosis and fascia are notcovered by striated muscle. These sites most commonly include the inguinal,femoral and umbilical areas, the linea alba, the lower portion of the semilunarline and sites of prior incisions1.

Herniausually appears as a lump, can cause pain, discomfort and limit daily activity.Hernia containing bowel if obstructed or strangulated, can become a life threateningcondition. Hernia repair is one of the most common operations in generalsurgery with rates of repair ranging from 10 per 10,000 populations in theUnited Kingdom to 28 per 10,000 in the United States2.

It isestimated that 5% of the population will develop an abdominal wall hernia, butthe prevalence may be even higher. Men are 25 times more likely to have a groinhernia than are women. An indirect inguinal hernia is the most common hernia,regardless of gender. In men, indirect hernias predominate over direct herniasat a ratio of 2 : 1. Direct hernias are very uncommon in women. Indirectinguinal hernia occur more commonly on the right side and is attributed to adelay in atrophy of the processus vaginalis after the normally slower descent ofthe right testis to the scrotum during fetal development1.

There havebeen many classifications proposed for groin hernias (tradition, Nyhus-Stoppa,modified Gilbert, Schumpelick/Aachen) but there are many controversies for themto be universally accepted3.

Though herniawas known for a long time, early management through the abdominal approach wasshort lived. Declaration by Tait4 that the radical cure of herniasshould be undertaken by abdominal section and later by Marcy5criticizing those sewing up a hole, rather than reconstructing the abdominaldefect, never became popular. After Bassini6, in 1884, the era ofthe abdominal approach came to an end. He laid down the basic principles forthe surgical repair of inguinal hernia. Later on modifications in the Bassini’stechnique have been described by McVay, Shouldice, and others, in an attempt toreduce the recurrence rate further.

Cheatle7,in 1920, introduced a new concept of preperitoneal repair for hernia repair.Later on,Nyhus et al.8, Rignault9 and Stoppa et al.10in 1980s, established the efficacy of the preperitoneal prosthetic inguinalhernioplasty.  Important contribution inthe field of inguinal herniorrhaphy is the tension free repair using anonabsorbable mesh, popularized by Lichtenstein et al.11. Even aftertraditional inguinal hernia repair, recurrence rates were ranging from 7% to21%12. And the absence of recurrence in 1000 cases reported byLichtenstein is the exception, and is attributed to the “tension-free herniarepairâ€.

Thelaparoscopic hernia repair is the alternative approach to open hernioplastywith almost same recurrence rates. Gerin 1979, performed the firsthuman laparoscopic herniorrhaphy13. Arregui14 in1992 described transabdominal preperitoneal repair (TAPP) and total extraperitonealrepair (TEP) was described by McKernan and Laws15 in 1993. It is based on sameprinciple that is “tension-free repairâ€, sound comprehension of anatomicrelationships, and it has all the advantages of minimal invasive surgery likeminimal patient discomfort, short hospitalization, and early return to workwithout restriction. Some complications unique to the laparoscopic approachlike those related to entering the abdominal cavity or complications at thetrocar site16 or the incidence of myalgia paresthetica17can be diminished by adequate laparoscopic training to become familiar with theanatomical features of the inguinal area.

Laparoscopicinguinal hernia repair (LIHR) today is an accepted technique for bilateralinguinal hernia. LIHR though technically more difficult at times to open repairhas got comparable results in relation to open hernia repair (OHR). Today thetwo most common laparoscopic techniques for inguinal hernia repair aretransabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP)repair. However lot of controversy exists between the exact choice ofprocedure.

 **Lacunae in existing knowledge:** There is insufficient data to make anyconclusion about the relative effectiveness of TEP compared with TAPP. Tilldate no randomized study is available comparing the two procedures in bilateralinguinal hernias 18.

**AIMSAND OBJECTIVES**

 1.      Toassess and compare intra-operative complications between transabdominalpreperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair forbilateral inguinal hernia.

 2.      Toassess and compare post-operative complications between transabdominalpreperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair forbilateral inguinal hernia.

  3.      Toassess and compare Post-operative recovery in terms of pain, bowelfunction, time to discharge & return to normal activities betweentransabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP)repair for bilateral inguinal hernia.

 4.      Toassess and compare intra-operative time between transabdominalpreperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair forbilateral inguinal hernia.

**MATERIALSAND METHODS**

1.     **PARTICIPANTS:** Allconsecutive patients with uncomplicated symptomatic bilateral inguinal herniaattending the surgery outpatient department at Lady Hardinge Medical College& associated hospitals were included in the study.

2.     **INCLUSIONCRITERIA: -**

**a.**Patient’s attending surgery OPD.

**b.**Uncomplicated symptomatic bilateral inguinalhernia

**c.**Consent for operation.

3.     **EXCLUSIONCRITERIA:**

**a.**Patient unfit for general anaesthesia.

**b.**Below 20 yrs and above 70yrs.

**c.**Previous lower abdominal surgery.

**d.**Pregnancy.

**e.**Past history of malignancy.

**f.**Complicated Hernia (Obstruction/emergencypresentations)

**g.**Severe Lower Urinary Tract Symptoms.

**h.**Morbid Obesity

**i.**Uncorrected coagulopathy

4.     **INTERVENTION:-**

**GroupI**: Transabdominal preperitoneal (TAPP) repair

**GroupII**: Totally extraperitoneal (TEP) repair

5.     **Figure:1- FLOW CHART:**-

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|Text Box: Enrolment

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Lost to follow up (give reasons) (n=       )

Discontinued intervention  (give reasons)(n=       )



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**Allocated to intervention  TEP (n=30)**

·         Received allocated intervention (n=     )

·         Did not receive allocated intervention (n=        )



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**Analysed (n=         )**

·         Excluded from analysis (give reasons) (n=          )



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**Analysed (n=         )**

·         Excluded from analysis (give reasons) (n=          )

Text Box: Analysis Text Box: Follow up

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Lost to follow up (give reasons) (n=       )

Discontinued intervention  (give reasons)(n=       )

Text Box: Allocation

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**Allocated to intervention  TEP (n=30)**

·         Received allocated intervention (n=     )

·         Did not receive allocated intervention (n=        )



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**Randomised (n=60)**

6.     **OUTCOME:-**

PRIMARY OUTCOME MEASURES

·        To assess and compare intra operative complicationsbetween transabdominal preperitoneal (TAPP) repair and totally extraperitoneal(TEP) repair of bilateral inguinal hernia.

·        To assess and compare post operativecomplications between) repair of transabdominal preperitoneal (TAPP) repairand totally extraperitoneal (TEP bilateral inguinal hernia.

 SECONDARYOUTCOME MEASURES

·        Post-operative recoverybetween transabdominal preperitoneal (TAPP) repair and totally extraperitoneal(TEP) repair of bilateral inguinal hernia.

·        Intra operative timecomparison between transabdominal preperitoneal (TAPP) repair and totallyextraperitoneal (TEP) repair of bilateral inguinal hernia.

 7.     **SAMPLESIZE CALCULATIONS:-** Aconvenient sample of 30 was taken in both groups

 8.     **RANDOMIZATION**:-

-      Block randomization usinga block size of ‘6’  was used.

-      Allocation concealmentand blinding couldn’t be done in this trial.

  9 **Statistical Analysis:**

Acomputerized grouped database was created with the following variables:

Group A - Continuous variables

1) Sex 2)  Age 3)  Weight, 4) Height 5)  Infra-umbilical girth6)  Size of defect,

7) Number of tacks used 8) Operative time 9)Pain scores 10) Hospital stay

11) Return to normal activity.

Group B - Categoricalvariables

1) Presenting complaints, 2) Hernia type, 3)Space creation difficulty, 4) Contents of           hernia sac, 5) Intra-operativeevents, 6) Blood loss, 7) Intra-operative complications,

8)Conversion to another laparoscopic or open approach, 9) Analgesic requirement,10) Nausea, 11) Vomiting, 12) Bowel movements, 13) Toleration of oral feeds,

14)Urinary retention, 15) Subcutaneous emphysema, 16) Seroma, 17) Haematoma, 18)Wound infection, 19) Recurrence, 20) Morbidity, 21)  Mortality.

  **Grading ofspace creation ease:**

The difficulty encountered in space creation in TEP was evaluatedusing an indigenously designed scoring system as tabulated below: [Scoreinterpretation: Mild <3, Moderate 4 – 8, Severe >9.]

    

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|Table 1

|**Findings**

**Points**

|No adhesions

1

|No peritoneal rupture/rent

1

|Mild blood loss.

1

|Adhesions + but could be easily separated

2

|Peritoneal rent created but managed easily

2

|Moderate blood loss

2

|Severe adhesions

3

|Large rent >5cm

3

|Severe blood loss

3

      The data was statistically analyzedusing SPSS version 17 software for the purpose.

Thedata was assessed for type of distribution : (normal/ non normal) Normallydistributed continous variables were assessed using parametric tests and nonnormally distributed data using non parametric test. Chi square test was usedfor categorical variables.  Repeatedmeasures test was used to assess postoperative pain scores.

        **RESEARCHQUESTION**

Is Transabdominal preperitoneal (TAPP) repairmore efficacious than totally extraperitoneal (TEP) repair for bilateralinguinal hernia?

**HYPOTHESIS:**Transabdominal preperitoneal (TAPP) repair is more efficaciousthan totally extraperitoneal (TEP) repair for bilateral inguinal hernia.

 **REVIEW OF LITERATURE**

An inguinal hernia is a defect in the abdominal wall, which allows escapeof intraperitoneal organs and present as a lump, with or without discomfortwhich may limit daily work and activities18. Primary inguinal hernia is a heterogeneous disease that with increasingage of the patient shows a rising incidence and also a tendency to bebilateral. Incarcerated and recurrent hernias extend the spectrum. The optimalsurgical approach must be selected individually for the patient, taking intoaccount patient age, hernia size, unilaterality or bilaterality, primary orrecurrent status, type of anesthesia, occupation, and leisure activities19. Operative techniques for the treatment ofinguino-femoral herniation can be broadly divided into two categories: Anteriorapproach via groin or a posterior approach via preperitoneal or transabdominalplane. An additional point of distinction between the various hernia repairtechniques is whether the posterior lamina of the transversalis fascia layer isto be reestablished with the use of sutures or through prosthetic reinforcement15.

 In 1884,Bassini’s anterior approach with high ligation of the sac and reinforcement ofthe floor was revolutionary which reduced the incidence of failure from 30 to10%6, 20. Since then twomajor revolutions have occurred during the last two decades for inguinal herniarepair. First was the tension free hernia repair by Lichtenstein in 1989 whichsignificantly reduced recurrence rates11 and became the most common repair throughoutthe world. Major advances of using a prosthetic mesh to bolster therepair without producing tension, and the posterior approach, which accuratelydefines the anatomy of the groin and allows the body’s own forces to helpreinforce the mesh repair have helped to reduce recurrence rates of groinhernia surgery to below 4%20,21,22,23,24.  Stoppa et al23and Nyhus et al8 have reported recurrence rates of less than 5%where they have used a large unsuturedpolyester prosthesis, placed preperitoneally, for inguinal hernia repair25 Intra abdominal pressure, rather thansuturing, was used to hold the mesh against the abdominal wall until subsequentadherence via connective tissue generation could occur15. The posterior approach reducedrecurrence by affording a better view of the groin, decreased the chance ofmissing a hernia defect and the mesh eliminated tension and reinforced anyintrinsic weakness20.

 The second revolution was the application of laparoscopic surgery to theinguinal hernia in early 1990’s. The first human laparoscopic herniorrhaphy wasperformed by Ger in 197913, his techniqueinvolved intra abdominal stapling of the neck of the hernial sac26. Introduction of laparoscopic techniques to the groin hernia had mixedresults of quick recovery but initially reported an unacceptably highrecurrence rates20. SinceGer et al there is a considerable increase in laparoscopic procedures foringuinal hernia27,28which have revolutionized the method of hernia surgery worldwide. Arregui14 in 1992 described transabdominalpreperitoneal repair (TAPP) and total extraperitoneal repair (TEP) wasdescribed by McKernan and Laws15 in 1993. The underlying final surgical goal of posterior, open (Stoppa,Wantz, Nyhus) and laparoscopic hernia repair (TAPP & TEP) is similar withmesh reinforcement of the preperitoneal space. LIHR though technicallymore difficult than open repair, now has got comparable or better results inrelation to open hernia repair (OHR).

 The advantages of the minimal access technique include less pain in theearly postoperative period, less need for narcotic and non narcotic analgesic,better cosmesis, early return to normal activity, with near total absence ofwound-related problems29,30. The advantages ofthe laparoscopic over the open approach in terms of reduced postoperative painand earlier return to usual activities have been confirmed by various studies31,32. The national institute ofclinical excellence (NICE) examined more than 40 randomized controlled trialsand reported that laparoscopic repair was indeed better than open inguinalhernia repair as it was associated with less pain and faster recovery, howeverlaparoscopy is more costly and required longer operating times33.

 Majorcontroversy exists between the exact choice among the most common laparoscopictechniques for inguinal hernia repair i.e transabdominal preperitoneal (TAPP)repair and totally extraperitoneal (TEP). If one is to give a general recommendation ofusage and a decisive indication, it is important to be able to state theparticularities and limitations of both procedures, the resulting quality beingof the utmost significance. Generally, there are differences in the specialsurgical techniques, which are of particular importance for the learning of thetechnique and its therapeutic result. Both procedures have in common that theyare mostly performed under general anaesthesia, it entitles a tension freereconstruction in the extraperitoneal space, implanting a flat mesh of 12 x 15cm size and in a way complete coverage of all the possible hernial sites in theinguinal region can be achieved. Both procedures can ideally combine theminimally invasive technique with the mechanical advantages of a tension freereconstruction. The predominant factors in successfulpreperitoneal hernia repair are adequate dissection of space and satisfactorydelineation of anatomy with complete exposure and coverage of the entiremyopectineal orifice.

In TAPPapproach, an infra-umbilical incision is used to gain access to the peritonealcavity directly. A peritoneal flap is created high on the anterior abdominalwall extending from the median umbilical fold to the anterior superior iliacspine. Space is created from the pubic symphysis medially to the level of theexternal iliac vein and laterally upto the anterior superior iliac spine. Care must be taken toavoid injury to the femoral branch of the genitofemoral nerve and the lateralfemoral cutaneous nerve, which are located lateral to and below the iliopubictract. Finally, the spermatic cord is skeletonised1.

 In TAPP asone enters the peritoneal cavity, it has a greater potential risk of damagingintra-peritoneal organs and adhesion formation leading to intestinalobstruction2,33. Overall complication rates with TAPP are low, withsmall bowel obstruction incidence of 0.2% to 0.5%34. This is usuallyattributed to inadequate peritoneal flap closure, trocar site herniation, oradhesions34. TEP may have all the advantages of an extraperitonealapproach but TAPP is considered easy to learn, perform and can be feasible evenfor irreducible hernia33.

 TEP isdifferent in that the peritoneal cavity is not entered and mesh is used to sealthe hernia from outside the peritoneum in preperitoneal space which may lessenthe risk of intra-abdominal organ injury. Preperitoneal space is createdthrough an infra-umbilical incision and inflating a balloon with bluntdissection to create a space beneath the rectus. The rest of the operationproceeds similar to a TAPP procedure1. Ramshaw et al quoted thatintra abdominal organ lesion is not impossible in TEP35. TEPcomplications can be varied ranging from anecdotal cases of mesh inducedappendicities to pnemothorax36. Laparoscopic total extraperitoneal (TEP) inguinal hernia repair can bedone under epidural anesthesia provided a minimal sensory level of T6 isachieved37. Pneumoperitoneum, shoulder-tip pain,intraoperative straining, and inadequate preperitoneal space are factors whoseinterplay leads to conversion to general anaesthesia (not the size of thedefect) 37. Daniel Let al in his study said that TEP approach for inguinal hernia, in patients withprevious lower abdominal surgery should be considered a relativecontraindication38.

 A multi-centric trial on laparoscopic inguinal hernia repairs done byRobert J. et al, concluded that laparoscopic inguinal hernia repair is aseffective as conventional repair with TAPP, IPOM, and TEP procedure appear tobe equally effective39. Anotherrandomized study conducted to evaluatethe merits of laparoscopic inguinal hernia repair (LIHR) compared toconventional open hernia repair (OHR) concluded both approaches were comparable in all aspects except for thegreater analgesic requirements in the open group to achieve this result26.

 Laparoscopic surgery does have a place for patients with bilateralhernias, recurrent hernias, or clinically doubtful hernias or in the case ofsmall symptomatic hernias a laparoscopic examination can clarify the nature ofany hernial defect26. There are manywho believe that LIHR is currently the preferred approach for recurrent herniasfrom previous open repairs and “Gold Standard†for bilateral hernias35,40*.*

 On the basis of the study conducted by C. Tamme on Totallyextraperitoneal endoscopic inguinal hernia repair (TEP) for unilateral orbilateral groin hernia, following concept of complementary methods for thetreatment of inguinal hernia were proposed19:

a)     Shouldice repair for primary hernias in young adults (Nyhus type 2) ifimplantation of a polypropylene mesh is rejected.

b)     Lichtenstein repair for large scrotal hernias when general anesthesia iscontraindicated and when anticoagulation therapy is needed.

c)     TEP for most indications, with additional advantages for bilateral,recurrent, and strangulated hernias.

 TEP isconsidered to be more difficult with a considerable learning curve than TAPPbut is thought to reduce post-operative pain2,28. In laparoscopic hernia repair, at times it’sthe experience of the operating team that seems to be more important thanchoice of technique. To emphasize the importance of the experience of operatingteam, one study was conducted to compare TAPP and TEP by Bobrzynski A et al.The mean operating time and hospitalization duration did not differ markedly.There was no procedure related mortality. Intra-operative complications wereinfrequent. The ratio of early local complication (neuralgia, hematoma, andseroma) was slightly higher in the TEP group and a higher recurrence rate wasseen following the TAPP procedure (2.84% vs 1.92%). But, after excluding thelearning period recurrence rates were comparable (TEP: 0.98% and TAPP: 1.14%)41.

In a study conducted by Ricardo V et al to determinethe most appropriate laparoscopic repair for inguinal hernia, they concludedthat both the techniques (TAPP & TEP) are safe and have the sameadvantages, but TAPP is easier which provides a better view of the anatomy withshorter learning curve. To determine recurrence rates, a longer follow upperiod and more cases are required42. Kald et al did aprospective nonrandomized study dealing with learning curve, complications, andearly results of laparoscopic TAPP and TEP approach in groin hernias. In thatstudy, mean operating time and hospital stays were same. Some majorcomplications like bowel obstruction, severe neuralgia, trocar hernias,epigastric artery bleeding and recurrences were found mainly in TAPP ascompared with other43.

A retrospective analysis done by Jean-Louis D. et al from 3,100 herniarepairs in both unilateral or bilateral hernias over 15 years. They concludedthat TEP is preferred over TAPP as the peritoneum is not violated and wasassociated with fewer intra-abdominal complications. For complicated hernias(sliding or incarcerated inguinal hernias) and hernias with previous pelvicsurgery like radical prostatectomy, TAPP approach had been advocated44.

 In the Cochrane Database Review18, eightnonrandomized studies were evaluated. The results suggested that TAPP isassociated with higher rates of port site hernia and visceral injuries whilethere appeared to be more conversions with TEP. Vascular injuries and deep/meshinfections were rare and comparable. However, there has been only onerandomized control trial (RCT)18 comparing TAPP andTEP and it reported that there is no statistically significant differencebetween the two with respect to duration of operation, hematoma, length ofstay, time to return to usual activities, and recurrences

 Aretrospective and nonrandomized study on laparoscopic TAPP and TEP was performedon 866 patients with either unilateral or bilateral hernia. Results suggestedthat both techniques shortened recovery and eliminated most early failures, butthe totally extraperitoneal approach reduced the potential for intraperitonealcomplications20. Fitzgibbonset al.45 concludedthat the factors leading to recurrence include surgeon inexperience, inadequatedissection, insufficient prosthesis size, insufficient prosthesis overlap ofhernia defects, improper fixation, prosthesis folding or twisting, missed hernias, or mesh lifting secondaryto hematoma formation.

 Krishna et al in their prospective randomized controlled trial on transabdominal preperitoneal(TAPP) versus totally extraperitoneal (TEP) approach which included bothunilateral and bilateral hernia concluded that TEP group had significantlyreduced postoperative pain up to 3 months and a better patient satisfactionscore. The other intra operative complications, postoperative complications,and cost of surgery were similar in both groups33. In a prospective nonrandomizedstudy on laparoscopic inguinal hernia repairs by G. A. Fielding, found thatover a period of 20.5 months, 3 recurrences were identified at 6, 7 and 12months, all were direct recurrences and all were after TAPP procedure46.Anothernonrandomized trial of LIHR was done on 115 patients with a total of 120hernias (60 in TAPP and 60 in TEP group) by Najib K et al. concluded thatlaparoscopic extra peritoneal repair can be accomplished with shorterhospitalization and less analgesic requirement and rest was comparable47.

A retrospective review was performed with emphasis on the comparison ofrecurrence rates and complication rates between these two laparoscopicapproaches by B. J. Ramshaw et al. The complication rate for the trans-abdominalapproach was 10.7% which included thigh paresthesias (6), inferior epigastricartery injuries (4), enterotomy (1), bowel obstruction (1), bladder injury (1),and urinary retention (14). The complication rate for the total extraperitonealapproach was 3.7% and included enterotomies (2), bladder injury (1),paresthesia (1), and urinary retention (6). Their results also show that therecurrence rates was 2.0% (6/300) for the transabdominal approach and 0.3%(I/300) for the total extraperitoneal approach. The recurrence, theenterotomies, and the bladder injury in the total extraperitoneal group, wereall in patients who had previous lower abdominal operations. In another review,all of the cutaneous nerve injuries and inferior epigastric vessel injury werein the TAPP group. To avoid vessel injury in the TAPP technique, they placedthe trocars lateral to the lateral border of the rectus muscle and visualizethe trocars as they enter the abdominal cavity35.

 There isscarcity of data from directly comparing the two procedures and question stillremains about its relative merits and risks. Methodologically sound RCTs areneeded to consider the relative merits and risks of TAPP and TEP48.Till date no randomized prospective study is available comparing the twoprocedures i.e, TAPP & TEP in bilateral inguinal hernias.

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Detailed Description

Not available

Study Timeline

• Study Start: 2009-01-10
• Last Update Posted: 2018-12-03

Recruitment & Eligibility

• Status: Completed
• Sex: All
• Target Recruitment: 60

Inclusion Criteria

• a.Patient’s attending surgery OPD.
• b.Uncomplicated symptomatic bilateral inguinal hernia c.Consent for operation.

Exclusion Criteria

• a.Patient unfit for general anaesthesia.
• b.Below 20 yrs and above 70yrs.
• c.Previous lower abdominal surgery.
• d.Pregnancy.
• e.Past history of malignancy.
• f.Complicated Hernia (Obstruction/emergency presentations) g.Severe Lower Urinary Tract Symptoms.
• h.Morbid Obesity i.Uncorrected coagulopathy.

Study & Design

• Study Type: Interventional
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
•To assess and compare intra operative complications between transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair of bilateral inguinal hernia.	0-6months
•To assess and compare post operative complications between) repair of transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP bilateral inguinal hernia.	0-6months

Secondary Outcome Measures

Name	Time	Method
•Post-operative recovery between transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair of bilateral inguinal hernia.	•Intra operative time comparison between transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair of bilateral inguinal hernia.

Trial Locations

Locations (1)

Department of Surgery; 🇮🇳 Delhi, DELHI, India

Department of Surgery

🇮🇳Delhi, DELHI, India

Deborshi Sharma

Principal investigator

9971539797

drdeborshi@gmail.com