Surgical Endoscopy (2022) 36:8298–8306 and Other Interventional Techniques

https://doi.org/10.1007/s00464-022-09281-z

Totally extraperitoneal laparoscopic inguinal hernia repair post‑radical

prostatectomy
Imogen Watt1,2 · Adam Bartlett1,2,3 · John Dunn2 · Andrew Bowker2

Received: 7 October 2021 / Accepted: 16 April 2022 / Published online: 17 May 2022
© The Author(s) 2022

Abstract
Background Previous radical prostatectomy (RP) is considered a relative contraindication to the laparoscopic approach for
inguinal hernia repair (LIHR). This study aimed to compare feasibility, safety and outcomes for patients undergoing totally
extraperitoneal (TEP) LIHR who have previously undergone RP.
Methods This single surgeon, case–control study was performed using a prospective database of all patients undergoing
TEP LIHR between 1995 and 2020. Patients who underwent previous RP were identified and compared to matched controls.
Pre-operative, operative and post-operative data were analysed. The type of RP, open, laparoscopic or robotic, was identified
and operative outcomes compared between the three groups.
Results 6532 LIHR cases were identified. 165 had previously undergone RP and 6367 had undergone primary LIHR without
prior RP. The groups were matched for age, demographics and co-morbidities. All operations were commenced laparoscopi-
cally, three converted to open in the LIHR + RP group and none in the LIHR group. Median operative time in patients with
previous RP was longer, for unilateral (40 min vs. 21 min, p < 0.0001) and bilateral (71 vs. 30 min, p < 0.0001) LIHR. The
majority of cases were performed as day stay procedures. There was no difference in immediate recovery parameters including
time to discharge, complication rates, return to normal function, return to driving or post-operative analgesia. At 3 months of
follow-up there was no difference in hernia recurrence for unilateral (2/128 vs 6/2234, p = 0.0658) or bilateral (0/24 vs 3/1490,
p ≥ 0.999) LIHR, nor chronic pain as measured by patient awareness or restriction of activity. No differences in operative and
post-operative outcomes were identified between the three types of RP, other than difference in operative time (p = 0.0336).
Conclusions Previous RP should not be an absolute contraindication for TEP LIHR. Although previous RP adds complex-
ity, in experienced hands TEP LIHR can be done safely, with outcomes equivalent to patients who have not previously
undergone RP.

Keywords Radical prostatectomy · Laparoscopic hernia repair · Totally extraperitoneal trans-abdominal preperitoneal ·
Laparoscopic inguinal hernia repair

Prostate cancer is one of the most commonly diagnosed seminal vesicles and, in some cases, the adjacent lymph
cancers in men and for localised cancer, RP is the treat- nodes [1, 2]. RP increases the risk of developing IH, with
ment of choice [1]. RP can either be performed by an open, 7–21% of patients post RP developing IH [2–5]. RP dis-
laparoscopic or robot-assisted approach, and involves dissec- rupts the preperitoneal plane and consequently increases the
tion through the preperitoneal space to resect the prostate, complexity of a laparoscopic repair. For this reason, pre-
vious RP is regarded as a contraindication to LIHR. Most
* Andrew Bowker surgeons advocate an open, anterior approach, avoiding the
[email protected] prostatectomy-related preperitoneal fibrotic reaction that can
make dissection in this plane challenging. LIHR repair offers
1
Department of Surgery, University of Auckland, Auckland, many advantages over the open technique, including shorter
New Zealand
hospital stay, faster post-operative recovery and return to
2
Laparoscopy Auckland, Gillies Ave, Epsom, Auckland, normal daily activities, reduced pain and improved cosmesis
New Zealand
[5]. To date fewer than 100 LIHR + RP operations utilising
3
Department of General Surgery, Auckland City Hospital, the TEP method have been published in the literature [2, 6].
Park Road, Auckland, New Zealand

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The primary aim of this study was to compare the Inclusions and exclusions
outcome of patients undergoing TEP LIHR post RP to
a matched control group undergoing LIHR without prior Exclusion criteria: females, non-inguinal hernia repair
groin surgery. The secondary aim was to compare the out- operations (femoral hernia), chronic groin pain without her-
come of patients relative to the RP approach. niation (groin strain/sportsman’s hernia), trans-abdominal
(TAPP) approach, patients undergoing a concurrent addi-
tional operation which might confer an increase in morbidity
Materials and methods and, for the LIIHR group, age ranges outside of age < 50
or > 87 years. Exclusion of ages outside of this range aligned
Study design and setting the LIHR group with the age range of the LIHR + RP group,
reducing any potential confounding factors. Operations
This retrospective case–control study analysed the out- were excluded in the sequence detailed above to ensure an
come of LIHR using the TEP approach in the context of excluded operation was only counted once.
previous RP. LIHR post RP was compared to primary In the LIHR + RP group, 13 operations were excluded
LIHR operations between 1995 and 2020, using informa- (9 unilateral, 4 bilateral). Exclusions were for the follow-
tion obtained from the prospective database of a single ing: femoral hernia (1), groin strain/sportsman’s hernia (2),
surgeon at a private surgical unit in Auckland, Aotearoa additional surgical procedure (8) and a TAPP approach (2).
New Zealand. Institutional approval was obtained for the The remaining 152 LIHR + RP operations were included in
study. the analysis, 128 unilateral and 24 bilateral (140 patients
A total of 6532 laparoscopic hernia repair opera- with prior RP). The types of initial RP techniques utilised
tions were identified and assessed for eligibility (Fig. 1). were open (93 of 140), robotic (18 of 140) or laparoscopic
Operations were divided into two groups. The first group (17 of 140) with 12 patients having unspecified type of prior
(n = 165) included LIHR post RP (LIHR + RP). The con- RP repair (Table 2).
trol group (n = 6367) included primary LIHR operations In the LIHR group, 2643 operations were excluded (1907
only. Patients undergoing unilateral and bilateral LIHR unilateral, 736 bilateral). Exclusions were for the follow-
were included. Bilateral repair was counted as two her- ing: female patient (340), femoral hernia (66), groin strain/
nia repair operations and compared like for like in the sportsman’s hernia (225), a TAPP approach (39), additional
analysis. surgical procedure (244) and age < 50 or > 87 years (1729).

Fig. 1  Consort diagram of patients undergoing TEP LIHR

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8300 Surgical Endoscopy (2022) 36:8298–8306

This left 3724 LIHR operations included in the analysis or non-steroidal anti-inflammatory drugs). At three months
2234 unilateral and 1490 bilateral (2979 patients). patients had phone call follow-up and were asked if they
had any residual awareness of the repair and if they had
Surgical technique any restriction in movement, or function, as a result of their
operation. Awareness and restriction were classified by the
Access to the extraperitoneal plane was gained through a patient as nil, mild, moderate or severe. Any presence of
short vertical incision in the ipsilateral anterior rectus sheath hernia recurrence was also recorded. Clinical review was
just below the level of the umbilicus, with introduction of offered to all patients.
a 0° 10 mm laparoscope. Two 5 mm operating ports were
placed in the lower abdominal midline below the umbilicus, Statistical analysis
via the linea alba. Balloon dissection was not used to reduce
the chance of peritoneal tearing against post-RP scarring. Descriptive statistics were used to characterise the groups,
The extraperitoneal space was developed working from lat- with mean and standard deviation (SD), or median and
eral, where tissues have not been previously dissected, to range. Groups were compared using Fisher’s Exact and Chi-
medial, where RP scarring is anticipated. A combination squared test for categorical data, the Mann–Whitney test for
of sharp and blunt dissection was employed, taking care to non-parametric numerical data, unpaired T-tests for para-
dissect against the posterior wall of the inguinal canal in metric numerical data and the Kruskal–Wallis and Dunn’s
areas of scarring, in order to avoid inadvertent injury of any test for multiple comparisons (GraphPad Prism 8.40, USA).
adherent bladder or bowel. Considerable care was exerted A p value < 0.05 was considered statistically significant.
when dissecting close to the iliac vessels. A 15 × 10 cm
polypropylene mesh was fixed to the periosteum of the
superior pubic ramus and the linea alba using penetrative Results
titanium tacs. Fixation laterally was not employed in order
to allow any subsequent mesh contraction to occur without Pre‑operative variables: (Tables 1 and 2, Fig. 2)
impediment. The aim was for day stay surgery. Patients were
encouraged to return to full activity, without any restric- There was a difference in age (p < 0.0001) between LIHR
tions regarding lifting/straining. Follow-up consisted of and LIHR + RP. The median age was 62 years for both
clinical review in 10–14 days and telehealth consultation at unilateral (IQR = 14y) and bilateral (IQR = 11y) LIHR,
3 months. The surgeon’s mobile phone number was provided compared to 68 for unilateral (IQR = 9.8y) and 71 for
for ease of contact if needed. bilateral (IQR = 11.8y) LIHR + RP. There was no differ-
ence in BMI (p = 0.2563 unilateral, p = 0.7379 bilateral) or
Variables analysed weight (p = 0.2295 unilateral, p = 0.4079 bilateral) between
LIHR and LIHR + RP groups. There were differences in
Quantitative and qualitative pre-operative, operative and the rates of previous hernia repair with 17.1% of unilateral
post-operative variables were assessed immediately prior to LIHR + RP operations identified as having a previous her-
surgery, at operation, at clinical follow-up (10–14 days post- nia repair on the contralateral side, compared to 10.5% for
operatively) and by telehealth 3 months post-operatively. unilateral LIHR (p = 0.0079). There was no difference in
Pre-operative variables included age, sex and body mass rates of previous hernia recurrence (p = 0.0658 unilateral,
index (BMI). Clinical variables assessed by the surgeon p > 0.9999 bilateral).
included hernia location (right or left), size (small, medium Previous RP technique was initially dominated by the
or large), whether the hernia was direct or indirect, and if the open method with 66% (93 of 140) undergoing open RP,
patient had previously undergone hernia repair. Operative 13% (18 of 140) robotic and 12% (17 of 140) laparoscopic
variables included the type of hernia, presence of lipoma of (Table 2). Previous RP technique was not specified in 9% (12
the spermatic cord, duration of operation (incision to wound of 140). As the study period progressed, robotic RP became
closure), perceived difficulty of operation by surgeon (visual the dominant contributor (Fig. 2).
analogue score of 1–10) and details of any concurrently per-
formed surgical procedure. Post-operative variables exam- Operative variables: (Tables 3 and 4, Fig. 3)
ined included hospital stay (classified as discharged on day
of surgery, the day following surgery or > 48 h) and any post- Three of the first 13 cases in the LIHR + RP series required
operative complications or readmission. Patient perceived conversion to open. These have been excluded from
variables included the number of days until return to nor- results analysis when looking at outcomes of (completed)
mal function, return to work, resumption of driving and the LIHR + RP. The median operative time was 21 min (range
number of days simple analgesia was required (paracetamol 9–120) for unilateral LIHR and 40 min (range 20–114) for

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Table 1  Pre-operative variables Pre-operative demographics

LIHR LIHR + RP
Unilateral Bilateral Unilateral Bilateral

Age (median) 62 (IQR = 14) 62 (IQR = 14) 68 (IQR = 9.8) 71 (IQR = 11.8)
Weight, kg (median) 80 79 78 78
BMI (median) 26 26 26 26
Previous hernia repair 235 34 24 1
(10.5%) (2.3%) (17.1%) (4.2%)
Previous hernia recurrence 208 137 6 1
(9.3%) (9.2%) (4.3%) (4.2%)
Total IHR 2234 (100%) 1490 (100%) 140 (100%) 24 (100%)

States the relevant numbers (either median and interquartile range, or whole numbers and percentage of
total) for the pre-operative demographics of age, weight, BMI, previous hernia repair and previous hernia
recurrence

Table 2  LIHR + RP initial prostatectomy technique Post‑operative variables: (Tables 5, 6, 7)

Radical prostatectomy: initial operation technique
Time to discharge was recorded as day of surgery, the day
Unilateral Bilateral Unliteral + Bilateral
following surgery or > 48 h post surgery, with no difference
Number of IHR 128 24 152 between LIHR and LIHR + RP (unilateral p > 0.9999, bilat-
Open 86 7 93 (66%) eral p = 0.0517). The majority were discharged on the day
Robotic 16 2 18 (13%) of surgery, 98.6% of unilateral LIHR, 97.9% of bilateral
Laparoscopic 14 3 17 (12%) LIHR, 94.5% of unilateral LIHR + RP and 91.7% of bilat-
Unknown/Unspecified 12 0 12 (9%) eral LIHR + RP. Only 10 patients (0.26%) were discharged
Number of prior RP 128 12 140 (100%) at > 48 h, none LIHR + RP. Complication rates were not dif-
ferent between LIHR and LIHR + RP (unilateral p = 0.2840,
States the original technique—open, laparoscopic, robotic or
unknown—of initial RP surgeries. This is shown as a whole number
bilateral p = 0.0621). Complications (e.g. hematoma or
and percentage of total LIHR + RP operations for both unilateral and superficial wound infection) occurred in 2.9% of unilateral
bilateral groups. Note that the 24 bilateral LIHR + RP operations are LIHR, 1.6% of bilateral LIHR, 2.1% of unilateral LIHR + RP
counted as 12 previous RP operations and 8.3% of bilateral LIHR + RP. No complications resulted
in loss of life or serious morbidity. Return to normal function
unilateral LIHR + RP, a 19-min difference (p < 0.0001). was not different between LIHR and LIHR + RP (unilateral
The median operative time was 30 min (range 16–105) p = 0.9034, bilateral p = 0.4025), with a mean of 3.5 days
for bilateral LIHR and 71 min (range 31–111) for bilat- (range 0–27) for unilateral LIHR, 3.8 days (0–18) for bilat-
eral LIHR + RP, a 41-min difference (p < 0.0001). Opera- eral LIHR, 3.5 days (0–10) for unilateral LIHR + RP and
tive time between open, robotic and laparoscopic unilat- 5.1 days (0–14) for bilateral LIHR + RP. Return to driving
eral LIHR + RP displayed a difference (p = 0.0336), with a was not different between LIHR and LIHR + RP (unilateral
median of 40 min (range 20–114) for open RP, 39.5 min p = 0.0513, bilateral p = 0.9320), with a mean of 2.2 days
(range 22–100) for robotic RP and 59 min (range 20–74) (range 0–11) for unilateral LIHR, 2.3 days (0–10) for bilat-
for laparoscopic RP. Comparison analysis by RP technique eral LIHR, 2.6 days (0–10) for unilateral LIHR + RP and
demonstrated a difference in operative time between lapa- 2 days (1–3) for bilateral LIHR + RP were reported. Anal-
roscopic vs. open (p = 0.0355) but no difference between gesic use was not different between LIHR and LIHR + RP
laparoscopic vs. robotic (p = 0.0937), or open vs. robotic (unilateral p = 0.1328, bilateral p = 0.7738), with a mean of
(p > 0.9999). 2.2 days (range 0–21) for unilateral LIHR, 2.6 days (0–14)
There was no difference in hernia size (p = 0.1563 uni- for bilateral LIHR, 2.7 days (0–16) for unilateral LIHR + RP
lateral, p = 0.2308 bilateral), side of herniation in unilateral and 3.2 days (0–10) for bilateral LIHR + RP.
cases (p = 0.7288) or element of lipoma (p = 0.5544 unilat- Awareness and restriction were assessed categorically
eral, p = 0.2808 bilateral) between LIHR and LIHR + RP. three months post-op, as no awareness versus awareness,
Indirect hernias were more common in the LIHR + RP and no restriction versus restriction, using the Chi-squared
group, 88% of unilateral and 68% of bilateral, compared to test. Losses to follow-up were 4.3% of unilateral LIHR, 10%
the LIHR group, 65% and 30%, respectively (Fig. 3). of bilateral LIHR, 11.4% of unilateral LIHR + RP and 25%

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Fig. 2  Radical prostatectomy operation type: trends over time. A line group. The year recorded is of hernia repair, not the year the radical
graph of which prostatectomy technique was utilised, open, robotic prostatectomy, as date of original operation was not always available,
or laparoscopic, in the operations included in the TEP LIHR + RP resulting in trend lines being shifted out of phase

Table 3  Operative variables Operative variables

LIHR LIHR + RP
Unilateral Bilateral Unilateral Bilateral

Conversion to open 0 (0%) 0 (0%) 3 (2.1%) 0 (0%)

Operative time, minutes 21 (IQR 9–120) 30 (IQR 16–105) 40 (IQR 20–114) 71 (IQR 31–111)
Right hernia 1263 (56.5%) 745 (50%) 74 (52%) 12 (50%)
Left hernia 971 (43.5%) 745 (50%) 66 (48%) 12 (50%)
Lipoma 238 (10.7%) 142 (9.5%) 11 (7.9) 4 (16.7%)
Total IHR 2234 (100%) 1490 (100%) 140 (100%) 24 (100%)

States the relevant numbers (either median and interquartile range, or whole number and percentage of
total) for the operative variables of conversion to open, operative time (in minutes), side of herniation and
presence of lipoma

of bilateral LIHR + RP. There was no difference in aware- of LIHR + RP (p = 0.7671). There was a difference in
ness between LIHR and LIHR + RP (unilateral p = 0.3689, restriction between unilateral LIHR and LIHR + RP, with
bilateral p = 0.0538), with 89.4% of unilateral LIHR, 90.8% restriction reported in 0.06% of LIHR vs. 0% of LIHR + RP
of bilateral LIHR, 92.0% of unilateral LIHR + RP and 88.9% (p = 0.0006), but no difference between bilateral LIHR and
of bilateral LIHR + RP reporting no awareness. There was LIHR + RP with no restriction reported in either group
no difference in awareness by RP technique, with aware- (p = 0.0563). There was no difference in restriction by RP
ness reported in 7.3% of open, 12.5% of robotic and 6.7% technique, with no restriction reported after any of the

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Table 4  LIHR + RP operative Radical prostatectomy

variables
Open Robotic Laparoscopic

Operative time, minutes (uni- 40 (IQR 20–114) 39.5 (IQR 22–100) 59 (IQR 20–74)
lateral only)
Conversion to open 2 (2.2%) 0 (0%) 0 (0%)
(unilateral + bilateral)
LIHR + RP 93 (100%) 18 (100%) 17 (100%)
(unilateral + bilateral)

States the operative variables of operation time (in minutes) and conversion to open, in the LIHR + RP
group, against initial RP type (open, robotic or laparoscopic)

Fig. 3  Hernia characteristics.

It is a pie graph demonstrating
the hernia characteristic in the
groups, simple laparoscopic
inguinal hernia repair opera-
tions compared to laparoscopic
inguinal hernia repair opera-
tions in the context of prior
radical prostatectomy. This is
further stratified by bilateral
and unilateral herniations to
allow for accurate comparative
analysis. Inguinal hernia char-
acteristics were recorded by the
surgeon as indirect or direct

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Table 5  Post-operative Post-operative variables: immediate recovery parameters

variables, recovery parameters
LIHR LIHR + RP
Unilateral Bilateral Unilateral Bilateral

Discharge the day of surgery 2203 (98.6%) 1458 (97.9%) 132 (94.5%) 22 (91.7%)
Complications 65 (2.9%) 24 (1.6%) 3 (2.1%) 2 (8.3%)
Return to normal function (days) 3.5 (IQR 0–27) 3.8 (IQR 0–18) 3.5 (IQR 0–10) 5.1 (IQR 0–14)
Return to driving (days) 2.2 (IQR 0–11) 2.3 (IQR 0–10) 2.6 (IQR 0–10) 2 (IQR 1–3)
Analgesia use (days) 2.2 (IQR 0–21) 2.6 (IQR 0–14) 2.7 (IQR 0–16) 3.2 (IQR 0–10)
Total IHR 2234 (100%) 1490 (100%) 140 (100%) 24 (100%)

States the relevant numbers, either median and interquartile range, or whole number and percentage of total
for the post-operative variables of time to discharge, complications, return to normal function, return to
driving and analgesia use

Table 6  Post-operative Post-operative variables: three-month follow-up

variables, three-month
follow-up LIHR LIHR + RP
Unilateral Bilateral Unilateral Bilateral

Initial group 2234 1490 140 24

Retained at 3 months 2138 (95.7%) 1341 (90%) 124 (88.6%) 18 (75%)
Lost to follow-up 96 (4.3%) 149 (10%) 16 (11.4%) 6 (25%)
No awareness 1911 (89.4%) 1218 (90.8%) 114 (92%) 16 (88.9%)
No restriction 2117 (99%) 1341 (100%) 124 (100%) 18 (100%)
Total IHR in follow-up 2138 (100%) 1341 (100%) 124 (100%) 18 (100%)

States the whole numbers and percentage total of the group, for the three-month post-operative variables of
lost to follow-up, awareness and restriction. Awareness and restriction are analysed as percentages from the
total of those retained at three-month follow-up

Table 7  Unilateral post-operative variables by radical prostatectomy p =  > 0.9999). Recurrence was reported in 0.27% of unilat-
technique, three-month follow-up eral LIHR (6 of 2234), 0.2% of bilateral LIHR (3 of 1490),
Radical prostatectomy: three-month follow-up (unilateral + bilateral) 1.6% of unilateral LIHR + RP (2 of 128) and 0% of bilateral
LIHR + RP cases (0 of 24). Of the two LIHR + RP recur-
Open Robotic Laparoscopic
rences, the first was considered a recurrence clinically, but
Initial group 93 18 17 on surgical exploration consisted of a small lipoma only.
Retained at 3 months 82 (88.2%) 16 (88.9%) 15 (88.2%) If this was excluded, unilateral LIHR + RP recurrence
Lost to follow-up 11 (11.8%) 2 (11.1%) 2 (11.8%) decreases to 0.78% (one in 128).
No awareness 76 (92.7%) 14 (87.5) 14 (93.3%
No restriction 82 (100%) 16 (100%) 15 (100%)
Total LIHR + RP in follow- 82 (100%) 16 (100%) 15 (100%) Discussion
up

States the whole numbers and percentage total, for three-month post- Previous RP, whether open, laparoscopic or robotic, should
operative variables in the LIHR + RP group, against initial RP type— not be considered an absolute contraindication to TEP
open, robotic or laparoscopic. Awareness and restriction are analysed LIHR. In this series, no difference in morbidity, mortality
as percentages from the total of those retained at three-month follow-
or recovery was demonstrated when comparing LIHR and
up
LIHR + RP, for either unilateral or bilateral repairs.
These findings are supported by the limited literature
LIHR + RP operations. Patients reported any awareness available on TEP inguinal hernia repairs. One systematic
or restriction as mild, moderate or severe, with no patients review published in 2019 [6] and two prospectively col-
reporting these as moderate or severe. lected case–control studies that included TEP hernia repair
There was no difference in hernia recurrence between in patients with previous RP were identified [7, 8]. These
LIHR and LIHR + RP (unilateral p = 0.0658, bilateral included a total of 277 LIHR operations (229 patients) in

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the context of previous RP and included both unilateral ego should not prevent sensible decision-making regarding
and bilateral repairs (181 unilateral and 48 bilateral) [6]. conversion to, or selection of, open repair. The outcome of
The majority of operations in these papers were performed longer operative time for LIHR + RP in this series reflects
using the TAPP approach, only 62 had a TEP repair [6]. the more challenging surgical environment post-RP second-
The 2019 systematic review reported no difference in ary to RP scarring, even in experienced hands. While there is
post-operative complications, conversions to open or her- increased difficulty in performing LIHR + RP, these results
nia recurrence between TEP and TAPP operative methods support that this is a hernia repair that can be performed by
[6]. The first case–control study looked at LIHR operations the experienced laparoscopic surgeon [15–17].
performed after RP or previous lower abdominal surgery, The dominance of indirect over direct inguinal hernias
matched to patients without previous surgery and included in the LIHR + RP group is explained by post-RP scarring,
10 TEP LIHR + RP operations from a total of 256 LIHR which is usually confined to the posterior wall of the inguinal
operations [7]. It concluded that, while TEP LIHR repairs canal, medial to the deep inguinal ring (Fig. 3). This scarring
post RP have a longer operative time when compared to is an impediment to direct hernia formation, but indirect
LIHR without prior RP, they can be performed efficiently herniation into the inguinal canal is relatively unimpeded.
and safely by experienced laparoscopic surgeons [7]. The Although the surgical literature considers RP a major risk
second case–control study reviewed outcomes for 52 TEP factor for inguinal hernia formation, in this series 18.75%
LIHR + RP operations, matched to a control group who had of unilateral LIHR + RP patients had a previous IHR on the
not undergone RP [8]. It concluded that TEP LIHR post RP contralateral side, compared to 10.47% of LIHR alone [2],
is safe, with equivalent outcomes to LIHR alone, and that the despite the two groups being matched for age and other con-
slightly longer operative times compared to an open hernia trols. These results suggest that an underlying susceptibility
repair may be justified by early discharge and reduced post- to hernia development may also be a contributing factor to
operative pain with LIHR [8]. hernia formation post RP, contrasting with the current surgi-
While publications on LIHR + RP are currently domi- cal perception.
nated by the TAPP method, there is no evidence supporting The results of this series allowed for some comparison
the superiority of the TAPP or TEP approach to hernia repair of the impact that the initial RP surgical technique—open,
[2, 6, 9–13]. Multiple, large, published analyses have found laparoscopic, or robotic—has on subsequent LIHR out-
TEP and TAPP comparable for all important post-operative comes. Although the numbers in this study are limited, they
outcomes including length of hospital stay, infection, her- suggest that initial RP technique does not impact on post-
nia recurrence and chronic pain [2, 10–14]. The choice of operative variables of awareness, restriction or recurrence in
hernia repair technique, TEP or TAPP is a matter of surgeon LIHR. The amount and density of scarring post RP varied
experience and preference [2, 10, 11]. The surgeon of this from case to case, with no apparent influence by original
series started performing LIHR using the TAPP technique, RP technique. As in many parts of the world, robotic RP is
switching to his preferred TEP approach in 1995. The results becoming the dominant technique in Aotearoa New Zealand,
of this paper in conjunction with the published literature but robotic RP did not appear to confer any increased ease of
demonstrate that both TEP and TAPP approaches are safe in subsequent LIHR compared to open or laparoscopic, though
the context of previous RP [2, 6, 9–11]. From this literature the numbers in this series are very small for meaningful
review, it appears that our series, which includes 152 cases analysis. We acknowledge that these are findings that would
of TEP LIHR + RP, is the largest study of TEP LIHR + RP need larger numbers and further research to form any defini-
currently published with only 62 other TEP LIHR + RP cases tive conclusions, but these results do seem promising that
found in the literature. Publications on TAPP LIHR + RP all patients who have undergone prior RP, regardless of RP
only support our conclusion that TEP LIHR post RP can be type, should be considered for LIHR. To our knowledge, this
performed safely. is the first publication to look at the impact of initial RP type
There is a significant learning curve to LIHR, whether on subsequent hernia repair.
TAPP or TEP is used. LIHR following RP confers an extra While this study has several limitations, it also demon-
layer of potential difficulty due to scarring of the extraperi- strates many strengths. Its largest limitation is that it is based
toneal plane over the posterior wall of the inguinal canal. off observational retrospective data. It is also limited in that
This is reflected in the surgeon of this series needing to con- there was only three-month follow-up and it is plausible
vert three of his first 13 LIHR + RP cases to open, despite that some hernia recurrence, an important post-operative
having done nearly 400 LIHR before embarking on his variable, was missed consequently. However, the variable
first LIHR + RP case. He recommends that any decision to being examined, prior RP, would make an RCT-based study
undertake LIHR post RP should only be made once a high impossible on ethical and practical grounds and all similar
level of competency with LIHR has been attained. There studies of this topic by nature will be observational retro-
is no set number of cases to achieve competency. Surgical spective studies. The large number of cases, 3876 overall,

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152 LIHR + RP, gives this study strength and reduces the in comparison to no operation and lymphadenectomy. J Urol
risk of bias despite its observational structure. Using data 166(3):964–967
5. Simons MP, Aufenacker T, Bay-Nielsen M et al (2009) European
from a single surgeon, over a period of 25 years, removes Hernia Society guidelines on the treatment of inguinal hernia in
intra-operative variability due to the surgical techniques and adult patients. Hernia 13(4):343–403
variances between surgeons. 6. La Regina D, Gaffuri P, Ceppi M et al (2019) Safety, feasibil-
In summary, previous RP should not be considered an ity and clinical outcome of minimally invasive inguinal hernia
repair in patients with previous radical prostatectomy: a system-
absolute contraindication for LIHR. Although previous RP atic review of the literature. J Minim Access Surg 15(4):281–286
adds complexity, in experienced hands TEP LIHR can be 7. Dulucq JL, Wintringer P, Mahajna A (2006) Totally extraperito-
done safely, with outcomes being equivalent to patients who neal (TEP) hernia repair after radical prostatectomy or previous
have not previously undergone RP. lower abdominal surgery: is it safe? A prospective study. Surg
Endosc 20(3):473–476
8. Le Page P, Smialkowski A, Morton J, Fenton-Lee D (2013)
Totally extraperitoneal inguinal hernia repair in patients previ-
Funding Open Access funding enabled and organized by CAUL and ously having prostatectomy is feasible, safe, and effective. Surg
its Member Institutions. Endosc 27(12):4485–4490
9. Morales-Conde S, Socas M, Fingerhut A (2012) Endoscopic
Declarations surgeons’ preferences for inguinal hernia repair: TEP, TAPP, or
OPEN. Surg Endosc 26(9):2639–2643
10. Bittner R, Montgomery MA, Arregui E et al (2015) Update of
Disclosures Imogen Watt, Adam Bartlett and John Dunn have no guidelines on laparoscopic (TAPP) and endoscopic (TEP) treat-
conflicts of interest or financial ties to disclose. Andrew Bowker runs ment of inguinal hernia (International Endohernia Society). Surg
teaching and mentoring seminars for surgeons learning laparoscopic Endosc 29(2):289–321
inguinal hernia repair, supported by Medtronic, which covers seminar 11. Aiolfi A, Cavalli M, Micheletto G et al (2019) Primary inguinal
expenses. He has no conflicts of interest or financial ties to disclose. hernia: systematic review and Bayesian network meta-analysis
comparing open, laparoscopic transabdominal preperitoneal,
Open Access This article is licensed under a Creative Commons Attri- totally extraperitoneal, and robotic preperitoneal repair. Hernia
bution 4.0 International License, which permits use, sharing, adapta- 23(3):473–484
tion, distribution and reproduction in any medium or format, as long 12. Aiolfi A, Cavalli M, Ferraro SD et al (2021) Treatment of inguinal
as you give appropriate credit to the original author(s) and the source, hernia: systematic review and updated network meta-analysis of
provide a link to the Creative Commons licence, and indicate if changes randomized controlled trials. Ann Surg 274(6):954–961
were made. The images or other third party material in this article are 13. Aiolfi A, Cavalli M, Del Ferraro S et al (2021) Total extraperi-
included in the article's Creative Commons licence, unless indicated toneal (TEP) versus laparoscopic transabdominal preperitoneal
otherwise in a credit line to the material. If material is not included in (TAPP) hernioplasty: systematic review and trial sequential analy-
the article's Creative Commons licence and your intended use is not sis of randomized controlled trials. Hernia 25(5):1147–1157
permitted by statutory regulation or exceeds the permitted use, you will 14. Wauschkuhn CA, Schwarz J, Bittner R (2009) Laparoscopic trans-
need to obtain permission directly from the copyright holder. To view a peritoneal inguinal hernia repair (TAPP) after radical prostatec-
copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. tomy: is it safe? Results of prospectively collected data of more
than 200 cases. Surg Endosc 23(5):973–977
15. Eyvaz K, Gokceimam M (2021) Crucial points in phases of totally
extraperitoneal (TEP) hernia repair. Learning curve analysis. Ann
References Ital Chir 92:720–727
16. Wakasugi M, Nakahara Y, Hirota M et al (2019) Learning curve
1. Sebesta EM, Anderson CB (2017) The surgical management of for single-incision laparoscopic totally extraperitoneal inguinal
prostate cancer. Semin Oncol 44(5):347–357 hernia repair. Asian J Endosc Surg 12(3):301–305
2. HerniaSurgeGroup (2018) International guidelines for groin her- 17. Bansal VK, Krishna A, Misra MC, Kumar S (2016) Learning
nia management. Hernia 22(1):1–165 curve in laparoscopic inguinal hernia repair: experience at a ter-
3. Alder R, Zetner D, Rosenberg J (2020) Incidence of inguinal her- tiary care centre. Indian J Surg 78(3):197–202
nia after radical prostatectomy: a systematic review and meta-
analysis. J Urol 203(2):265–274 Publisher's Note Springer Nature remains neutral with regard to
4. Lodding P, Bergdahl C, Nyberg M, Pileblad E, Stranne J, Hugos- jurisdictional claims in published maps and institutional affiliations.
son J (2001) Inguinal hernia after radical retropubic prostatec-
tomy for prostate cancer: a study of incidence and risk factors

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