Primary inguinal hernia : systematic review and Bayesian network meta-analysis comparing open, laparoscopic transabdominal preperitoneal, totally extraperitoneal, and robotic preperitoneal repair

Purpose: The Open Lichtenstein technique, the Laparoscopic Trans-Abdominal PrePeritoneal (TAPP), the Totally Extra Peritoneal (TEP), and the robotic TAPP (rTAPP) are commonly performed. The aim of the present network meta-analysis was to globally compare short-term outcomes within these major surgical techniques for primary unilateral inguinal hernia repair. Methods: PubMed, EMBASE, and Web of Science were consulted. A fully Bayesian network meta-analysis was performed. Results: Sixteen studies (51.037 patients) were included. Overall, 35.5% underwent Open, 33.5% TAPP, 30.7% TEP, and 0.3% rTAPP. The postoperative seroma risk ratio (RR) was comparable considering TAPP vs. Open (RR 0.91; 95% CrI 0.50–1.62), TEP vs. Open (RR 0.64; 95% CrI 0.32–1.33), TEP vs. TAPP (RR 0.70; 95% CrI 0.39–1.31), and rTAPP vs. Open (RR 0.98; 95% CrI 0.37–2.51). The postoperative chronic pain RR was similar for TAPP vs. Open (RR 0.53; 95% CrI 0.27–1.20), TEP vs. Open (RR 0.86; 95% CrI 0.48–1.16), and TEP vs. TAPP (RR 1.70; 95% CrI 0.63–3.20). The recurrence RR was comparable when comparing TAPP vs. Open (RR 0.96; 95% CrI 0.57–1.51), TEP vs. Open (RR 1.0; 95% CrI 0.65–1.61), TEP vs. TAPP (RR 1.10; 95% CrI 0.63–2.10), and rTAPP vs. Open (RR 0.98; 95% CrI 0.45–2.10). No differences were found in term of postoperative hematoma, surgical site infection, urinary retention, and hospital length of stay. Conclusions: This study suggests that Open, TAPP, TEP, and rTAPP seem comparable in the short term. The surgical management of inguinal hernia is evolving and the effect of the adoption of innovative minimally invasive techniques should be further investigated in the long term. Ultimately, the choice of the most suitable treatment should be based on individual surgeon expertise and tailored on each patient.