figure 1.png

Comparison of Outcomes of Open Tension-free Mesh Repair and Totally Extraperitoneal Laparoscopic Repair of Inguinoscrotal Hernias

Shazi Bhekithemba, Koto Modise, Osuagwu Chukwuemeka, Schoeman Hermanus

Department of Surgery, Sefako Makgatho Health Sciences University, Pretoria, 0204, South Africa.

Correspondence to: Dr. Shazi Bhekithemba, Email:

Received: 28 April 2020; Revised: 04 July 2020; Accepted: 25 July 2020; Available online: 31 July 2020


Background: This study aimed to determine the differences in postoperative complications experienced by patients with inguinoscrotal hernia after laparoscopic versus open repair, and the association of risk factors to development of postoperative complications. Methods: We retrospectively reviewed the charts of all patients with inguinoscrotal hernias who had either Lichtenstein repair or totally extraperitoneal laparoscopic (TEP) repair from January 2014 to December 2017. Results: The study was performed on evaluable data that could be extracted for 49 patients: 14 were offered TEP repair and 35 Lichtenstein repairs. There was no statistical difference in the mean operative time and mean time taken to return to normal activities between the two groups. The length of hospital stay was one day for both groups. Two patients from the TEP repair group and one patient from the Lichtenstein repair group developed recurrence. Three patients from the TEP group and one patient from the Lichtenstein repair group developed chronic groin pain. One patient from the totally extraperitoneal laparoscopic repair group developed a seroma. Conclusion: Our study demonstrated a trend towards better postoperative outcomes in the Lichtenstein repair group than in the TEP group.

Keywords: Open tension-free mesh repair, Totally extraperitoneal laparoscopic repair, Inguinoscrotal hernias

Ann Afr Surg. 2021; 18(1):29–33


Conflicts of Interest: None

Funding: None

© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.


Inguinal hernia is a common surgical condition with a reported incidence of 1.5–5% of the population (1). The natural history of inguinal hernia is either incarceration or strangulation. Patients with an indirect inguinal hernia who present late are also likely to have an inguinoscrotal hernia. In a setting where there is no significant delay in providing repair to patients who present to a healthcare facility early with an indirect inguinal hernia, one should expect to find very few patients who present with inguinoscrotal hernias. Thus, few studies from developed countries looked at inguinoscrotal hernias.

Inguinal hernia repair can be performed as an open procedure or laparoscopically. Some of the surgical techniques for open inguinal hernia repair include Bassini, Shouldice, McVay and Lichtenstein. Lichtenstein repair is the most common open technique that uses mesh to repair an inguinal hernia. It is regarded as the gold standard and the most commonly performed open repair at Dr George Mukhari Academic Hospital, South Africa. Laparoscopic repair can be either totally extraperitoneal laparoscopic repair (TEP) or transabdominal preperitoneal repair (TAPP). TEP is the preferred laparoscopic method of repair at our institution. The best method of repairing inguinal hernias has remained a controversial topic. However, TEP repair is superior in terms of less postoperative pain and early recovery in inguinal hernias (1). 

Before Lichtenstein repair became the standard operation in the management of inguinal hernias, recurrence of post tissue repair was as high as 50–60% but came down to approximately 1–4% with the use of mesh (2). However, some believe that tissue repair, such as Shouldice repair, also produces excellent results in high-volume centers. Other postoperative complications after inguinal hernia repair include seroma, chronic groin pain and mesh sepsis. TEP repair of inguinal hernia was introduced in 1990. The introduction of laparoscopy in the management of inguinal hernia is regarded as another important development in the search for an ideal method of repairing inguinal hernia. Laparoscopy appears to have short-term advantages than Lichtenstein repair (3). However, TEP repair has been found to be costlier than Lichtenstein repair (4). Studies comparing the two approaches are more on inguinal hernias and not so much on inguinoscrotal hernias. We performed our study to ascertain if there were differences in postoperative outcomes, especially recurrence, seroma and chronic groin pain, in patients with inguinoscrotal hernia post either laparoscopic TEP repair or Lichtenstein repair, and to determine any association between risk factors and comorbid conditions to postoperative complications.          


Patients and Methods

Our study took place at a teaching hospital with 1652 beds. The hospital still relies on a cabinet storage system to keep patients’ files. As a result, a significant number of patients’ files get lost. Permission to undertake the study was obtained through applying to the Executive Management, and ethical clearance was obtained from the institutional Research Committee. 

Our study included all male patients 18 years and older with a unilateral inguinoscrotal hernia who were offered either TEP or Lichtenstein from January 2014 to December 2017. The study was a retrospective cross-sectional chart review. Details of patients who had undergone repair of an inguinoscrotal hernia were obtained from their files. These included demographic data, comorbid conditions, smoking status, type of repair, operative time, length of hospital stay, time taken to return to normal activities, visceral or vascular complications, and mortalities.

All patients post-repair would be given a 2-week follow up clinic visit where the treating surgeon would enquire about time of return to normal activities and assess the patient for wound complications. Patients were called at 12 months to provide information pertaining to chronic groin pain and recurrence. We defined giant inguinoscrotal hernias as inguinoscrotal hernias that extended beyond the scrotum towards the mid-thigh area. Operative time was calculated in minutes, starting from the time of skin incision to skin closure.

Exclusion criteria included patients with giant inguinoscrotal hernias, recurrent hernias, bilateral hernias, those younger than 18 years of age, those who had had tissue repair (typically done for patients who presented as emergencies where there was a possibility of contamination of bowel contents or translocation of bacteria), and