title: Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study.
abstract: BACKGROUND
  Creation of extraperitoneal space during TEP repair requires an expensive commercially available balloon.
  
  
  METHODS
  Fifty-six patients suffering from uncomplicated primary unilateral or bilateral groin hernia were randomized into two groups; group 1--indigenous balloon dissection and group 2--direct telescopic dissection.
  
  
  RESULTS
  There were 55 males and 1 female, with an average age of 49 years; 50% of the inguinal hernias were bilateral. Creation of extraperitoneal space was considered as satisfactory in majority of patients (94.6%) with satisfactory anatomical delineation. Peritoneal breach was noticed during dissection in 36 (64.3%) patients. There was one (3.8%) conversion of TEP to TAPP in group 2. Distance between pubic symphysis to umbilicus was an important factor, which affected the easiness of dissection. In patients with this distance <or=14 cm lateral placement of ports was considered for easy use of graspers. The incidence of scrotal edema was significantly higher in group 2 as compared with group 1 (p < 0.01). Patients with indirect inguinal hernias in group 2 presented with a greater number of scrotal edema. Pain score on VAS at 6 h after surgery was significantly higher in group 2 (p < 0.021). Patients with age <65 years, bilateral hernias, and indirect hernias had a correlation with higher pain score at 6 h. Of the patients, 17.9% developed seroma in group 1 versus 64.3% in group 2 (p < 0.001).
  
  
  CONCLUSIONS
  Anatomical delineation of inguinal area and dissection in the extraperitoneal space in TEP repair was equally satisfactory with both low-cost indigenous balloon (group 1) and telescopic dissection (group 2). Balloon dissection was associated with significantly reduced postoperative pain at 6 h, scrotal edema, and seroma formation. However at 3 months follow-up balloon dissection did not offer significant advantage over direct telescopic dissection in the overall long-term outcome of TEP repairs. If balloon dissection is considered useful for the beginner, low-cost indigenous balloon may be used to avoid higher cost of commercially available balloon dissector with added early advantages.
authors.affiliation: Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi 110029, India. mcmisra@gmail.com
authors.forename: Mahesh C
authors.initials: MC
authors.lastname: Misra
authors.forename: Sareesh
authors.initials: S
authors.lastname: Kumar
authors.forename: Virinder K
authors.initials: VK
authors.lastname: Bansal
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000886:Anthropometry; D002404:Catheterization / Q000191:economics / Q000295:instrumentation* / Q000379:methods; D003906:Developing Countries; D004210:Dissection / Q000295:instrumentation / Q000379:methods*; D004867:Equipment Design; D005260:Female; D005932:Gloves, Surgical; D006552:Hernia, Inguinal / Q000601:surgery*; D006801:Humans; D007194:India; D010535:Laparoscopy / Q000191:economics / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D012307:Risk Factors; D013526:Surgical Mesh