Systematic review and meta-analysis of clinical trials comparing endoscopic totally extraperitoneal inguinal hernioplasty with open repair of inguinal hernia

Abstract

Objective: Endoscopic totally extraperitoneal inguinal hernioplasty (TEP) has been gaining in popularity in recent years. However, there has been little data to support the superiority of TEP over open repair. The objective of the present systematic review was to compare the effectiveness of open and endoscopic totally extraperitoneal approaches for the repair of inguinal hernias. Data sources: A search of electronic databases, including MEDLINE, EMBASE and the Cochrane Library, was conducted to identify appropriate articles published between January 1990 and March 2002. In addition, a manual search for other studies was undertaken by reviewing the bibliographic reference list of the retrieved articles, contents of surgical journals and proceedings of conferences. Review methods: Only those studies that reported randomized trials comparing the outcomes between TEP and open repair of inguinal hernias were included. The quality of recruited trials was assessed critically by using a scoring system modified by Evans and Pollock. The effect size of outcome parameters was estimated by odds ratio or weighted mean difference where appropriate. Results: Ten randomized trials, which included 3212 patients, were recruited in the present systematic review. Meta-analysis reviewed a significantly lower wound complication rate after TEP (odds ratio (OR)=0.50, 95% confidence interval (CI)=0.37-0.69, P<0.001). In all trials, patients who underwent TEP reported less postoperative pain than those who underwent open repair. The pooled effect of four trials with usable data of pain score also favoured TEP (weighted mean difference (WMD)=-0.26, 95% CI =-0.36 to -0.16, P<0.001). Patients returned to normal activities significantly earlier after TEP than those who underwent open repair (WMD=-0.23, 95% CI=-0.31 to -0.15, P<0.001). However, the mean operative duration of TEP was significantly longer than that of open repair (WMD=0.54, 95% CI=0.23-0.85, P<0.001). With regard to the recurrence rate, the overall meta-analysis favoured TEP. However, when open repair was categorized into either suture herniorrhaphy or mesh hernioplasty, the recurrence rate after TEP remained superior to sutured herniorrhaphy (OR=0.54, 95% CI=0.31-0.96, P=0.03) but was comparable to that following open mesh hernioplasty (OR=1.76, 95% CI=0.60-5.22, P=0.09). Conclusions: Meta-analyses proved that TEP conferred significant early postoperative benefits, including a lower wound morbidity rate, faster return to normal activity and reduced postoperative pain at 1 week. With regard to the recurrence rate, TEP was superior to sutured herniorrhaphy, but showed a similar efficacy to open mesh hernioplasty. Future meta-analyses of randomized controlled trials are required to evaluate the long-term outcomes of TEP and open mesh hernioplasty.