A systematic review comparing single-incision versus multi-incisionlaparoscopic surgery for inguinal hernia repair with mesh*
M.S. Sajid a, *, A.H. Khawaja a, M. Sayegh b, M.K. Baig a
a Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex,BN11 2DH, UKb Department of General, Upper Gastrointestinal & Hepato-pancreatico-biliary Surgery, Western Sussex Hospitals NHS Foundation Trust, Worthing HospitalWorthing, West Sussex, BN11 2DH, UK
h i g h l i g h t s
� Single incision laparoscopic inguinal (SILS) hernia repair has several advantages such as better cosmesis and reduced pain score and analgesicsrequirements.
� This study presents meta-analysis of fifteen comparative studies on 1651 patients undergoing SILS versus conventional multi-incision laparoscopic(MILS) inguinal hernia repair.
� The recovery time was significantly quicker in SILS compared to MILS group� However, the statistical equivalence was seen in outcomes of length of hospital stay, operative time both for unilateral and bilateral hernias, post-operative pain score, one-week pain score, recurrence, conversion [odds ratio, and post-operative complications.
� Both SILS and MILS approaches of laparoscopic inguinal hernia repair are feasible, safe and can be offered to patients depending upon the availability ofexpertise and resources.
a r t i c l e i n f o
Article history:Received 4 November 2015Received in revised form19 February 2016Accepted 20 February 2016Available online 11 March 2016
* The provisional abstract of this study has been preInternational Surgical Congress of the Associations ofIreland (ASGBI) from 22nde24th April 2015 in MPublished citation Br J Surg 2015; 102(102): 43.* Corresponding author. Worthing Hospital, Washin
Objective: The objective of this article is to evaluate whether the surgical outcomes differ between singleincision laparoscopic surgery (SILS) versus multi-incision laparoscopic surgery (MILS) for the repair ofinguinal hernia.Methods: A systematic review of the literature on published studies reporting the surgical outcomesfollowing SILS versusMILS for inguinal hernia repairwas undertaken using the principles ofmeta-analysis.Results: Fifteen comparative studies on 1651 patients evaluating the surgical outcomes in patients un-dergoing SILS versus MILS for inguinal hernia repair were systematically analysed. The post-operativerecovery time was significantly quicker [odds ratio, �0.35 (CI, �0.57 e 0.14), p ¼ 0.001] following SILScompared to MILS procedure. However, the statistical equivalence was seen in outcomes of length ofhospital stay, operative time both for unilateral and bilateral hernias, post-operative pain score, one-week pain score, hernia recurrence [odds ratio, 1.24 (CI, 0.47e3.23), p ¼ 0.66], conversion [odds ratio,1.07 (CI, 0.37e3.12), p ¼ 0.90], and post-operative complications [odds ratio, 0.95 (CI, 0.66e1.36,p ¼ 0.78] between two approaches. The sub-group analysis of four included randomized, controlled trialsshowed similarities between outcomes following SILS and MILS except slightly higher postoperative painscore in MILS group.Conclusions: Both SILS and MILS approaches of inguinal hernia repair are feasible, safe and can be offeredto patients depending upon the availability of expertise and resources.
sented as an oral paper at theSurgeons of Great Britain andanchester, United Kingdom.
gton Suite, North Wing, West
Sajid).
f of IJS Publishing Group Ltd.
1. Introduction
Inguinal hernia is one of the most common general surgicalcondition comprising 7% of all surgical outpatient visits [1]; itsrepair being the most common general surgical procedure with
M.S. Sajid et al. / International Journal of Surgery 29 (2016) 25e3526
over 20 million of inguinal hernia repairs performed worldwideevery year [2,3]. A lifetime risk of developing inguinal hernia isestimated to be 27% for men and 3% for women [4]. Various tech-niques have been used to repair inguinal hernia since the firstcomprehensive technique described by Bassini in 1887 [5]. Atpresent three techniques remains the mainstay of repair of inguinalhernia. a) Shouldice repair which is the primary repair of herniawith surgical suture and it is almost obsolete in clinical practiceexcept in emergency situations, b) Open “tension free” mesh repairtechnique pioneered by Lichtenstein in 1984 which is still consid-ered the method of choice for primary inguinal hernia and c) thelaparoscopic mesh placement, which is considered a gold standardtreatment for recurrent and bilateral hernias [6e8]. The laparo-scopic repair of inguinal hernia by either total extra-peritoneal(TEP) approach or trans-abdominal pre-peritoneal (TAPP)approach has gained immense popularity in last two decadesowing to its advantages of less postoperative pain, quicker recoverytime, better cosmetic results and the opportunity to examine thecontralateral side [9e15] in addition to its role in the managementof bilateral and recurrent hernias [13].
Conventional laparoscopic inguinal hernia (TEP or TAPP) repairusually requires three ports sized 5 mme10 mm and a total skinincision length analogous with that of an open repair. Efforts werebeingmade to lessen the post-operative pain and improve cosmeticresult produced as a result of surgical trauma resulting from theincisions required. Consequently, this led to the emergence of
Fig. 1. PRISMA
single-incision laparoscopic surgery (SILS); the first case of SILS-TEPwas performed in 2008 by FilipoviceCugura [16]. There have beennumber of studies and case reports discussing its feasibility andsafety [17e24] in the medical literature. Good clinical outcomes interms of lesser requirements of analgesia and superior cosmesis[25,26] following SILS approach for laparoscopic repair of inguinalhernia is rapidly taking over the multi-incision laparoscopic sur-gery (MILS). The aim of this systematic review is thus to comparethe outcome of SILS and MILS for inguinal hernia repair in pub-lished randomized, non-randomized and comparative studies.
2. Methods
To find relevant articles for this review, a search of electronicdatabases such as PubMed, Medline, EMBASE and the CochraneLibrary was conducted using the standardmedical subject headings(MeSH) without the limits for language, gender, sample size andthe place of study. The references of the published articles werehand searched to find additional studies that may have beenmissedby the literature search. The data of all types of comparative trials(randomized, non-randomized) was collected and analysed sys-tematically to achieve a combined outcome for the purpose ofgeneration of a conclusive evidence. The statistical analysis of theextracted data was conducted according to the guidelines providedby the Cochrane Collaboration including the use of RevMan 5.3®
statistical software, random-effects model analysis, heterogeneity
flow chart.
Table 1Characteristics of included trials.
Study Year Country Patients Age in years Male: Female Study design
de Araujo et al. [35] Retrospective matched pair group analysisSILS Brazil/USA 56.5 ± 3.51 Not reportedMILS 2014 50 57.7 ± 3.29Bharathi et al. [36] Retrospective cohort studySILS 5 (1e14) 98:4MILS 2008 India 163 5 (1.5e14) 45:6Bialecki et al. [37] Prospective controlled clinical trialSILS 35:0MILS 2014 Poland 61 60 (26e77) 26:0Buckley et al. [38] Retrospective studySILS 55.57 ± 7.9 119:10MILS 2014 USA 205 55 ± 18.24 71:5Cugura et al. [39] Randomized controlled trialSILS 58.5 (20e84)MILS 2012 Croatia 44 55.0 (17e79) 44:0Kim et al. [40] Retrospective analysis of prospectively collected dataSILS South Korea 59.9 ± 13.2 72:4MILS 2013 169 59.5 ± 13.5 87:6Sato et al. [41] Prospective, controlled clinical trialSILS 64.3 28:7MILS 2012 Japan 85 61.0 45:5Sherwinter et al. [42] Retrospective analysis of prospectively collected dataSILS 37.5 ± 11.9 46:6MILS 2010 USA 104 33.7 ± 11.3 50:2Tai et al. [43] Retrospective analysis of prospectively collected dataSILS Taiwan/USA 46.9 ± 13.6 48:6MILS 2011 139 56.4 ± 14 81:4Tran et al. [44] Randomized, controlled trialSILS 48 (18)MILS 2014 Australia 100 54 (24) Not reportedTsai et al. [45] Randomized, controlled trialSILS Taiwan/USA 55.4 ± 15.1 44: 6MILS 2013 100 53.2 ± 17.2 45: 5Uchida et al. [46] Retrospective analysis of prospectively collected dataSILS 51.1 ± 35 31:29MILS 2010 Japan 177 57.9 ± 35.5 50:67Wakasugi et al. [47] Retrospective analysisSILS 65 ± 12 87:13MILS 2015 Japan 137 61 ± 14 34: 3Wijerathne et al. [48] Randomized trialSILS 46 (±11) 26: 0MILS 2014 Singapore 50 45 (±12) 24: 0Yang et al. [49] Retrospective analysis of prospectively collected dataSILS 61.7 (28e88) 29:3MILS 2015 China 67 61.5 (38e81) 32:3
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testing by chi-squared test, heterogeneity quantification by I-squared test and the use of forest plots for the graphical display ofthe combined outcomes [27e31]. Themethodological quality of theincluded randomized trials was initially assessed using the pub-lished guidelines of Jadad et al. and Chalmers et al. [32,33]. Theshort summary of the resulting evidence was presented in atabulated form by using GradePro® [34] tool, provided by theCochrane Collaboration.
3. Results
3.1. Study selection
Fifteen comparative studies (4 randomized controlled trials, 2non-randomized, controlled trials and 9 retrospective studies)were considered suitable for the pooled analysis [35e49]. ThePRISMA flow chart to explain the literature search strategy and trialselection is given in Fig. 1. The characteristics of included trials aregiven in Table 1. In total 1651 patients evaluating the surgical out-comes in patients undergoing SILS versus MILS for inguinal herniawere systematically analysed. There were 860 patients in the SILS
group and 791 patients in the MILS group. Two trials were con-ducted on paediatric patients [36,46] and the remaining thirteen[35,37e45,47e49] studies were carried out on adult patients.Eleven studies [35,36,38e40,42e45,47,48] compared patients un-dergoing total extra peritoneal (TEP) repair; two studies [36,46]reported laparoscopic percutaneous extra-peritoneal approach onpaediatric patients and two studies [41,49] were conducted usingboth the TEP and the TAP approaches for inguinal hernia repair.
3.2. Risk of bias assessment in included studies
The tabulated summary of resulting evidence is given in Fig. 2.Table 2 shows the quality indicator of included randomized,controlled trials.
3.3. Combined analysis of all studies
3.3.1. Duration of operation for unilateral inguinal hernia repairAs shown in Fig. 3a, ten studies reported the duration of oper-
ation for unilateral inguinal hernia repair [35,36,38,41e44,46,47].In the random effects model analysis (SMD, �0.07; 95% CI, �0.38,
Fig. 2. GradePro summary of evidence.
Table 2Reported RCT quality indicators.
Study Randomization Power calculations ITT Blinding Concealment Jadad score
Cugura et al. [39] Yes Yes No No Not Reported 3Tran et al. [44] Yes Yes Yes Yes Yes 4Tsai et al. [45] Yes Yes Yes No Yes 4Wijerathne et al. [48] Yes Yes Not reported Yes Yes 4
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Fig. 3. a- Forest plot for duration of operation of unilateral inguinal hernia by SILS versus MILS. Standardized mean difference is shown by 95% confidence interval. SILS: Singleincision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for duration of operation of bilateral inguinal hernia by SILS versus MILS. Standardized meandifference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for length of hospital stay in SILSversus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
M.S. Sajid et al. / International Journal of Surgery 29 (2016) 25e35 29
0.23; z ¼ 0.48; P ¼ 0.63), the duration of operation for unilateralhernia repair was statistically similar in both SILS and MILS groups.There was significant heterogeneity (Tau2 ¼ 0.17, c2 ¼ 34.80, df¼ 9,[P < 0.0001]; I2 ¼ 74%) among included studies.
3.3.2. Duration of operation for bilateral hernia repairAs shown in Fig. 3b, ten studies reported the duration of oper-
ation for bilateral inguinal hernia repair [35,36,38,39,41e44,46,47].In the random effects model analysis (SMD, 0.02; 95% CI, �0.40,
Fig. 4. a- Forest plot for pain score on post op 1st day in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. SILS: Single incisionlaparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for pain score on post op one week in SILS versus MILS of inguinal hernia. Standardized meandifference is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for conversion of cases in SILSversus MILS of inguinal hernia. Odds ratio is shown by 95% confidence interval. SILS: Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
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0.44; z ¼ 0.09; P ¼ 0.93), the duration of operation for bilateralhernia repair was also statistically similar following SILS and MILSprocedures. There was significant heterogeneity (Tau2 ¼ 0.24,c2 ¼ 24.92, df ¼ 9, [P ¼ 0.003]; I2 ¼ 64%) among included studies.
3.3.3. Length of hospital stayAs shown in Fig. 3c, eight studies [35,39e41,43,45,47,48]
contributed to the combined calculation of this variable. In the
random effects model analysis (SMD, �0.04; 95% CI, �0.32, 0.24;z ¼ 0.29; P ¼ 0.77), the length of hospitalization was also foundstatistically similar in both groups. There was significant hetero-geneity (Tau2 ¼ 0.07, c2 ¼ 12.82, df ¼ 5 [P ¼ 0.03]; I2 ¼ 61%) amongincluded studies.
3.3.4. Day 1 post-operative pain scoreAs shown in Fig. 4a, six studies reported the pain score on the
Fig. 5. a- Forest plot for complications in SILS versus MILS of inguinal hernia. Odds Ratio is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for recurrent cases after SILS versus MILS of inguinal hernia. Odds ratio is shown by 95% confidence interval. Single incision laparoscopicsurgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for recovery time for patients after SILS versus MILS of inguinal hernia. Standardized mean difference is shown by95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
M.S. Sajid et al. / International Journal of Surgery 29 (2016) 25e35 31
first post-operative day [37,40,43e45,48]. In the random effectsmodel analysis (SMD,�0.14; 95% CI,�0.41, 0.13; z¼ 1.03; P¼ 0.30),the pain score after 24 h of the surgery was statistically similar inboth SILS and MILS groups. There was significant heterogeneity(Tau2¼ 0.07, c2¼13.18, df¼ 5, [P¼ 0.02]; I2¼ 62%) among includedstudies.
3.3.5. Day 7 post-operative pain scoreAs shown in Fig. 4b, six studies reported the pain score on day 7
[37,40,43e45,48]. In the random effects model analysis(SMD,�0.27; 95% CI,�0.56, 0.01; z¼ 1.89; P ¼ 0.06), the pain scorewas statistically similar in both groups. There was significant het-erogeneity (Tau [2] ¼ 0.08, c2 ¼ 14.75, df ¼ 5, [P ¼ 0.01]; I2 ¼ 66%]among included studies.
Fig. 6. a- Forest plot for operating time for hernia in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incisionlaparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for length of hospital stay in RCT's in SILS versus MILS of inguinal hernia. Standardized mean dif-ference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. c- Forest plot for pain score on post-op 1st day in RCT'sin SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopicsurgery.
M.S. Sajid et al. / International Journal of Surgery 29 (2016) 25e3532
3.3.6. Laparoscopic to open conversion rateAs shown in Fig. 4c, ten studies reported conversion of the
procedure [35,36,38,40,41,44,45,47e49] to open hernia repair. Inthe random effects model analysis (OR, 1.07; 95% CI, 0.37, 3.12;z ¼ 0.13; P ¼ 0.90), the conversions rate was similar in both groups.There was no heterogeneity (Tau2 ¼ 0.00, c2 ¼ 1.35, df ¼ 4,[P ¼ 0.85]; I2 ¼ 0%) among included studies.
3.3.7. Post-operative complicationsAs shown in Fig. 5a, twelve studies reported the post-operative
complications [35e38,40e43,45,47e49]. In the random effectsmodel analysis (OR, 0.95; 95% CI, 0.66, 1.36; z ¼ 0.28; P ¼ 0.78), thepost-operative complication rate was also similar in MILS and SILsgroups. There was no heterogeneity (Tau2 ¼ 0.00, c2 ¼ 4.51, df¼ 11,[P ¼ 0.95]; I2 ¼ 0%) among included studies.
3.3.8. Recurrence of herniaAs shown in Fig. 5b, thirteen studies reported the recurrence of
inguinal hernia [35-39,41,43-49.] In the random effects modelanalysis (OR, 1.24; 95% CI, 0.47, 3.23; z ¼ 0.44; P ¼ 0.66), the risk ofrecurrent hernia was similar in both groups. There was no het-erogeneity (Tau2 ¼ 0.00, c2 ¼ 3.26, df ¼ 6, [P ¼ 0.78]; I2 ¼ 0%)among included studies.
3.3.9. Post-operative recovery timeAs shown in Fig. 5c, four studies [35,42e44] contributed to the
combined calculation of this variable. In the random effects modelanalysis (SMD,�0.35; 95% CI,�0.57,�0.14; z¼ 3.19; P¼ 0.001), therecovery time was faster following SILS compared to MILS. Therewas no heterogeneity (Tau2 ¼ 0.01; c2 ¼ 3.41, df ¼ 3 [P ¼ 0.33];I2 ¼ 12%) among included studies.
3.4. Subgroup analysis of four randomized trials only
3.4.1. Duration of operationAs shown in Fig. 6a, the combined analysis of three randomized,
controlled trials [44,45,48], the random effects model analysis(SMD, 0.31; 95% CI,�0.30, 0.92; z¼ 0.99; P¼ 0.32) showed that theduration of operation for hernia repair was statistically similar inSILS andMILS groups. However, therewas significant heterogeneity(Tau2 ¼ 0.24, c2 ¼ 11.11, df ¼ 2, [P ¼ 0.004]; I2 ¼ 82%) amongincluded randomized studies.
3.4.2. Length of hospital stayAs shown in Fig. 6b, hospital stay was reported by three ran-
domized trials [39,45,48]. In the random effects model analysis(SMD, 0.05; 95% CI, �0.79, 0.89; z ¼ 0.13; P ¼ 0.90), no statisticaldifference was found among both the groups.
Fig. 7. a- Forest plot for pain score on post-op 1st week in RCT's in SILS versus MILS of inguinal hernia. Standardized mean difference is shown by 95% confidence interval. Singleincision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery. b- Forest plot for complications in RCT's in SILS versus MILS of inguinal hernia. Odds ratio is shown by 95%confidence interval. Single incision laparoscopic surgery, MILS: Multi-incision laparoscopic surgery.
M.S. Sajid et al. / International Journal of Surgery 29 (2016) 25e35 33
3.4.3. Day 1 pain scoreAs shown in Fig. 6c, pain score on first post-operative day was
reported by three randomized trials [44,45,48]. In the random ef-fects model analysis (SMD �0.43; 95% CI �0.71, �0.16; z ¼ 3.09;p ¼ 0.002), the day 1 pain score was significantly lower in SILSgroup.
3.4.4. Day 7 pain scoreAs shown in Fig. 7a, the day 7 pain score was reported in three
randomized, controlled trials [44,45,48] which was statisticallysimilar (SMD,�0.24; 95% CI,�0.72, 0.23; z¼ 1.00; P¼ 0.32) in bothgroups.
3.4.5. Post-operative complicationsAs shown in Fig. 7b, all causes post-operative morbidity was
reported in two included randomized, controlled trials [45,48]which showed similar risks in both groups of laparoscopicinguinal hernia repair.
4. Discussion
Laparoscopic surgery since its advent in early 1990's isincreasingly being preferred by the surgeons and patients world-wide due to its overall benefits evident by operative results andpatient satisfaction [50]. With almost similar results to open meshrepair, laparoscopy provides an alternative to inguinal hernia repairespecially in bilateral or recurrent cases [51]. Single incision surgeryis a step forward to enhance the same advantages as reducing thenumber of surgical incisions, may potentially lessens the analgesiarequirement and potential sites where post-operative infectionmay occur. However, technical challenges posed by the procedureare responsible for a longer learning curve for surgeons. The con-ventional concepts of necessary triangulation in laparoscopic sur-gery and limited operative field space are impending reasons forprolonged duration of the operation and unique iatrogenic injuries.Despite showing promising results, the SILS approach for inguinalhernia has failed to demonstrate a clinically proven advantage over
the MILS approach and based upon the findings of current studystatistical equivalence may be extrapolated.
4.1. Limitations
This systematic review is a combined analysis of randomizedand non-randomized, controlled trials with variable inclusion andexclusion criteria of patient recruitment. Furthermore, the ap-proaches of TEP and TAPPwere adopted at surgeon's choice and theavailability of resources. Therefore, the combined outcomes maynot be considered free from bias. Diverse inclusion and exclusioncriteria, variable pain measuring tools in included trials and dis-similar duration of follow up may well be responsible for clinical,methodological and statistical heterogeneity among includedstudies. Similarly, inconsistencies in the types and size of laparo-scopic ports used, use of different types of mesh and experience ofthe operating surgeons pose an added bias to the outcomes of thisstudy. A high quality, multi-centre randomized, controlled trial isthus required to validate the findings of this study prior to therecommendation of the routine use of SILS for inguinal herniarepair.
5. Conclusion
This systematic review shows the safety of SILS and its efficacyin the management of inguinal hernia repair but its statisticalequivalence to MILS fails to approve its routine use. No statisticaldifference as compared to MILS in operating time, post-operativecomplications and recurrence rates of hernia may make this tech-nique be more conveniently adopted by surgeons in future iftraining and resources are available. Despite showing promisingresults, SILS approach for inguinal hernia has failed to demonstratea measureable clinically proven advantage over MILS approach andbased upon the findings of current study statistical equivalencemay be extrapolated.
M.S. Sajid et al. / International Journal of Surgery 29 (2016) 25e3534
Conflict of interest
None to declare.
Financial support
None to declare.
Sources of funding
None to declare.
Ethical approval
Not applicable.
Author contribution
Mr MS Sajid: Study idea, literature search, trial selection, dataextraction and analysis and article writing.
AH Khawaja: Data extraction, trial selection, article proofreading.
Mr M Sayegh: Data confirmation, Data interpretation, articleproof reading.
Mr MK Baig … Data confirmation, data interpretation, proofreading.
Guarantor
Mr MS SAJID.
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