Feasibility of Re-TREPP in Patients With a Recurrent Inguinal Hernia After Previous TREPP Repair

Study Overview
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Brief Summary
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The Trans REctussheath PrePeritoneal (TREPP) mesh repair was introduced in 2006 to decrease the risk of postoperative inguinal pain in hernia surgery. For the repair of a recurrent inguinal hernia after a primary TREPP an alternative open anterior route (Lichtenstein) may seem the most logical option, but coincides with an increased risk of chronic postoperative inguinal pain. Therefore, this study aimed to evaluate the feasibility of a second TREPP procedure to repair a recurrent inguinal hernia after an initial TREPP repair. The hypothesis was that the technique is possible and does not lead to an increased risk of postoperative pain.

Detailed Description
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Since the development and introduction of TREPP in 2006, TREPP has been the standard operation technique for all patients who present in St. Jansdal Hospital with an inguinal hernia. The electronic patient files of all consecutive patients who were operated at the St Jansdal hospital via TREPP between January 2006 and December 2013 were retrospectively investigated. This patient list was retrieved by an electronic search using the assigned operation codes. Adult patients who had developed a recurrent inguinal hernia and had undergone a re-TREPP were included in this study. A case report form was filled in for each patient that underwent a re-TREPP. Baseline data such as operation time, Body Mass Index (BMI), operation technique, number of conversions, aetiology of the recurrence, type of anesthesia and American Society of Anesthesiology (ASA) classification were retrospectively reviewed through patient files and operation reports. Co-morbidities were extracted from the files. Information on short term complications was taken from the notes of telephone consultation 2 and 30 days postoperatively, which is the local standard protocol for follow-up. Patients were invited for a long-term follow-up (>30 days postoperative) at the outpatient department for physical examination, or they were visited at home by the investigator. Written informed consent was obtained from all patients who were included for a long term follow-up. A case report form was used for each patient, in order to standardize the investigation. All patients were asked if they experienced any pain or discomfort. If there was pain, the Visual Analogue Scale and Pain Disability Index questionnaire were filled in. All patients were asked if sexual complaints occurred since the operation. Written informed consent was obtained from all patients who were clinically evaluated. Recurrent inguinal hernia was defined as a reappearance of the inguinal hernia, diagnosed by physical examination (a reducible bulge with positive Valsalva). This was a retrospective case series. Since the numbers were small, no statistical analysis was performed.

Official Title
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Management of Recurrent Inguinal Hernia After Previous Open Preperitoneal Repair: Is Re-TREPP Feasible?

Conditions
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Recurrent Inguinal Hernia

Intervention / Treatment
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* Procedure: re-TREPP


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult patients who had developed a recurrent inguinal hernia and had undergone a re-TREPP. Exclusion Criteria: Children (age <18 years) Exclusion criterium for long term follow up: no informed consent obtained.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| re-TREPP<br>Patients who presented with a recurrent inguinal hernia after previous TREPP repair. | Procedure: re-TREPP<br>* repeated hernia repair via the TREPP technique<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Chronic postoperative inguinal pain according to Visual Analogue Scale. | All patients who reported chronic pain (>30 days postoperative) were asked to fill out the Visual Analogue Scale. This was a horizontal line of 100 millimeters long. Patients were asked to mark the point that indicated the amount of pain that they experienced. The length between the left anchor 'no pain' and the patients mark was measured, providing a range of 0 to 100. A greater score indicated greater pain intensity. | This was assessed between >30 days postoperative and the moment of evaluation (up to 95 months postoperative). | 
| Chronic postoperative pain according to Pain Disability Index | All patients who reported chronic pain (>30 days postoperative) were asked to fill out the Pain Disability Index questionnaire. | This was assessed between >30 days postoperative and the moment of evaluation (up to 95 months postoperative). | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Re-recurrence rate | The number of second recurrences after re-TREPP repair | This was assessed by reviewing the electronic patient files and via a physical examination at the long term follow-up (ranging from >30 days postoperative, up to 95 months postoperative). | 
| Short term complications | Short term complications included: hematoma, wound infection, re-admission rate, medical complications and death. These complications were retrospectively analyzed via the electronic patient files. | Complications occuring from the start of the operation up to 30 days postoperative. | 
| Sexual complaints related to re-TREPP | All patients were asked if they experienced any sexual problems related to the re-TREPP surgery. The question was answered with 'yes', 'no' or 'not sure'. | This was assessed between >30 days postoperative and the moment of evaluation (up to 95 months postoperative). | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Inguinal Hernia, TREPP, Recurrence