A comparative study of efficacy of laparoscopic transabdominal pre-peritoneal-plus versus intraperitoneal onlay mesh-plus repair for small umbilical hernias.

Abstract

<h4>Introduction</h4>Umbilical hernias are a frequent subset of ventral hernias. Although laparoscopic intraperitoneal onlay mesh with defect closure (IPOM-plus) repair is widely used, concerns remain about mesh contact with viscera and associated pain. The transabdominal pre-peritoneal with defect closure for umbilical hernias (TAPPu-plus, where 'u' denotes umbilical) approach attempts to mitigate such complications by placing the mesh in a pre-peritoneal pocket. This study compares the feasibility, operative time, post-operative pain, hospital stay and recurrence rates between TAPPu-plus and IPOM-plus techniques for small-sized (≤4 cm) umbilical hernias.<h4>Patients and methods</h4>A prospective, single-centre randomised controlled trial was conducted on 50 symptomatic patients with primary umbilical hernias measuring ≤4 cm. Patients were randomised in a 1:1 ratio into Group A (TAPPu-plus, n = 25) or Group B (IPOM-plus, n = 25) using block randomisation with sealed opaque envelopes. Mesh repair was performed in all patients. The primary outcome was procedural feasibility. Secondary outcomes included operative time, estimated blood loss, post-operative pain visual analogue scale, analgesic use, hospital stay and 1-year recurrence.<h4>Results</h4>All procedures were completed laparoscopically. Two patients in the TAPPu-plus group were converted to IPOM-plus due to restricted dissection space, resulting in 23 patients in Group A and 27 in Group B for final analysis. TAPPu-plus was associated with a longer operative time (117.3 ± 14.9 min vs. 80.5 ± 19.7 min), but significantly lower post-operative pain scores throughout follow-up. Estimated intraoperative blood loss was lower in the TAPPu-plus group (mean 1.68 vs. 2.55 soaked gauze pieces [6 cm × 6 cm]; P < 0.01). The mean hospital stay was also shorter in the TAPPu-plus group (5.4 vs. 6.9 days, P < 0.01). No recurrences were observed in either group at 1-year follow-up.<h4>Conclusion</h4>Both techniques were safe and effective for laparoscopic repair of small umbilical hernias. TAPPu-plus, although more technically demanding, demonstrated superior outcomes in post-operative pain control and recovery. It represents a promising alternative to IPOM-plus in appropriately selected patients when performed by experienced surgeons.