# Three-Arm Registry-Based Comparison of Trans-Inguinal-Pre-Peritoneal, Laparoscopic, and Lichtenstein Techniques for Scrotal Hernia Repair

## TL;DR

This study compares three surgical techniques for scrotal hernia repair and finds they are similarly effective, with each having specific advantages.

## Contribution

The study introduces TIPP as a valid alternative for scrotal hernia repair, comparable to laparoscopic and Lichtenstein techniques.

## Key findings

- TIPP, Lichtenstein, and laparoscopic techniques showed similar recurrence rates and complication rates.
- Laparoscopic repairs had better nerve preservation and higher day surgery rates in less complex cases.
- Lichtenstein was often used for more complex patients and hernias, acting as a fallback procedure.

## Abstract

Studies on minimal invasive open preperitoneal techniques performed in scrotal hernia repair are very scarce.

We conducted a comparative study based on the prospectively collected data of the “Club-Hernie.” A scrotal hernia was defined as an inguinal hernia which has descended into and causes any distortion of the scrotum. Giant inguinal hernias were not included.

A total of 3,043 scrotal hernias repairs, performed from 01/09/2011 to 30/04/2023, met the inclusion criteria. The late results of 395 Trans-Inguinal-Pre-Peritoneal (TIPP/MOPP), compared with those of 1038 Lichtenstein and those of 1610 laparoscopic (TEP/TAPP) repairs were globally similar. At a median follow-up of 2 years, no significant difference was found between the three groups regarding the rate of identified recurrences (0.6% vs. 0.6% vs. 0.7%; p=0.9191; p=0.7435) and the prevalence of severe CPIP (0.6% vs. 0.4% vs. 0.7%; p=0.6772; p=0.7300, respectively for TIPP, Lichtenstein and TEP/TAPP). Each technique, though, showed some benefits and drawbacks. Laparoscopic repairs, used in this series in less complex patients (lower number of ASA 3-4 patients and/or patients on anticoagulants) and hernias (lower rates of L3/M3 defects), provided a better nerve preservation (nerve resection /= III) postoperative complications and a high rate of day surgery (69.9%). The hernia sac was completely resected in 64% of cases without injury of the spermatic cord nor need for a unilateral orchidectomy. Probably due to preoperative tailoring, the Lichtenstein group significantly collected many of the most complex patients (ASA3-4: 31.8%; anticoagulant therapy: 23.4%) and the most symptomatic hernias (severe preoperative pain: 17.5%). Lichtenstein was not only a default technique but also a fallback procedure: Fifteen (40.5%) of the 37 conversions occurring in laparoscopic or TIPP techniques ended up in a Lichtenstein technique.

This study shows that TIPP is feasible, safe and effective in scrotal hernias, providing results close to those of laparoscopic techniques. Thus, TIPP appears as a valid alternative when the aim is to elect both a preperitoneal repair and a minimal invasive open route. Having the choice of effective techniques may help in tailoring the treatment of these so particular types of groin hernias.