title: Total extraperitoneal inguinal hernia repair compared with Lichtenstein (the LEVEL-Trial): a randomized controlled trial.
abstract: BACKGROUND
  This randomized controlled trial was designed to compare the most common technique for open mesh repair (Lichtenstein) with the currently preferred minimally invasive technique (total extra peritoneal, TEP) for the surgical correction of inguinal hernia.
  
  
  METHODS
  A total of 660 patients were randomized to Lichtenstein or TEP procedure. Primary outcomes were postoperative pain, length of hospital stay, period until complete recovery, and quality of life (QOL). Recurrences, operating time, complications, chronic pain, and costs were secondary endpoints. This study was registered at www.clinicaltrials.gov and carries the ID: NCT00788554.
  
  
  RESULTS
  About 336 patients were randomized to TEP, and 324 to Lichtenstein repair. TEP was associated with less postoperative pain until 6 weeks postoperatively (P=0.01). Chronic pain was comparable (25% vs. 29%). Less impairment of inguinal sensibility was seen after TEP (7% vs. 30%, P=0.01). Mean operating time for a unilateral hernia with TEP was longer (54 vs. 49 minutes, P=0.03) but comparable for bilateral hernias. Incidence of adverse events during surgery was higher with TEP (5.8% vs. 1.6%, P<0.004), but postoperative complications (33% vs. 33%), hospital stay and QOL were similar. After TEP, patients had a faster recovery of daily activities (ADL) and less absence from work (P=0.01). After a mean follow-up of 49 months, recurrences (3.8% vs. 3.0%, P=0.64) and total costs (euro3.096 vs. euro3.198) were similar.
  
  
  CONCLUSIONS
  TEP procedure was associated with more adverse events during surgery but less postoperative pain, faster recovery of daily activities, quicker return to work, and less impairment of sensibility after 1 year. Recurrence rates and chronic pain were comparable. TEP is recommended in experienced hands.
authors.affiliation: Department of Surgery, Erasmus MC, Rotterdam, The Netherlands. h.langeveld@erasmusmc.nl
authors.forename: Hester R
authors.initials: HR
authors.lastname: Langeveld
authors.forename: Martijne
authors.initials: M
authors.lastname: van't Riet
authors.forename: Wibo F
authors.initials: WF
authors.lastname: Weidema
authors.forename: Laurents P S
authors.initials: LP
authors.lastname: Stassen
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.forename: Johan
authors.initials: J
authors.lastname: Lange
authors.forename: Hendrik J
authors.initials: HJ
authors.lastname: Bonjer
authors.forename: Johannes
authors.initials: J
authors.lastname: Jeekel
mesh_terms: D000203:Activities of Daily Living; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D015337:Multicenter Studies as Topic; D010147:Pain Measurement; D010149:Postoperative Pain / Q000453:epidemiology; D011788:Quality of Life; D012008:Recurrence; D013526:Surgical Mesh