Laparoscopic Total Extraperitoneal (TEP) repair of inguinal hernias using manual dissection instead of a balloon dissector— potential cost savings

Simran K Randhawa, MD, Lawrence N Cetrulo, Alisan Fathalizadeh, MD, Pak S Leung, MD, Danielle Bilsland, BSN, Amit R Joshi, MD, FACS. Einstein Healthcare Network

Background: Inguinal hernia repair is the most common procedure performed by a general surgeon.  With growing use of laparoscopic inguinal herniorrhaphy, the purpose of this study is to outline a modified technique using focused (non-balloon) dissection and evaluate its impact on operative time and post-operative pain.

Methods: We performed a retrospective review of all patients, from 2011 to 2015, who underwent an ambulatory laparoscopic TEP repair of a unilateral primary inguinal hernia with mesh by a single surgeon.  The conventional surgical technique was modified by eliminating the employment of a balloon dissector to create the extra-peritoneal space.  Instead, focused manual dissection from the anterior superior iliac spine to the pubis was performed.  We measured operative time and immediate post-operative narcotic requirement.

Results: A total of 32 patients met the inclusion criteria.  All cases were completed laparoscopically using polyester mesh and absorbable spiral tacks.  There were no intra- or post-operative complications.  Mean operative time was 116.63 ± 24.27 minutes (range 35-179 minutes). The mean oral and intravenous narcotic use was 16.37±8.63 mg of oral oxycodone equivalent/patient.  No recurrences were observed in this group.

Conclusion: The technique of focused dissection without a balloon insufflator provides a cost-effective method of laparoscopic TEP repair that aims towards reducing operative time and post-operative pain control.  It is also a useful technique in resource-depleted settings, where balloon dissectors may not be available or may be too expensive, consequently saving the hospital nearly $320 per case.  Further randomized control trials will be necessary to validate the study.  

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