Laparoscopic Inguinal Hernia Repair: Art or Evil

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Laparoscopic Inguinal HerniaRepair Art or Evil
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Inguinal Hernias

• How common are they?
• - 700,000 inguinal hernia repairs performed in
  the US per year

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Inguinal Hernia

• Types Indirect Direct -- separated by inf
  epigastric vessels

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Open Inguinal Hernia Repairs

• Bassini
• McVay
• Shouldice
• Lichtenstein
• Plug patch

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Lichtenstein Repair

• Popularized the use of polypropylene mesh in
  primary hernia repairs
• Mesh is laid over the undisturbed inguinal floor,
  posterior to the spermatic cord sutured to the
  shelving edge of the inguinal ligament, internal
  oblique fascia and the pubis

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Laparoscopic Hernia Repair
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When is laparoscopy appropriate?

• Recurrent hernias - avoid a prev operated field
• Bilateral hernias - one set of incisions better
  than two inguinal incisions one mesh to cover
  both overlay bladder

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Types of Laparoscopic Inguinal Hernia Repair

• IPOM (IntraPeritoneal On-lay Mesh) repair. A
  mesh is placed intra-abdominally covering the
  hernia defect and then secured to the abdominal
  wall. Very popular at the beginning of
  laparoscopic experience, it has since been
  abandoned.
• TAPP  (Trans Abdominal Pre-Peritoneal) repair.
  With this technique, the pre-peritoneal space is
  accessed from the abdominal cavity and a mesh is
  then placed and secured. This is procedure of
  choice for recurrent inguinal hernias or in case
  of incarcerated bowel visualized.
• TEP (Totally ExtraPeritoneal) repair. The mesh
  is again placed in the retroperitoneal space, but
  in this case, the space is accesed without
  violating the abdominal cavity. This is probably
  the most physiological repair although
  technically more demanding. The procedure of
  choice for bilateral inguinal hernia repairs

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Trochar placement for both TEP TAPP
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Anatomy
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What does the literature say ?
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Comparison of Conventional Anterior Surgery and
Laparoscopic Surgery for Inguinal-Hernia
RepairMike S.L. Liem, M.D., Yolanda van der
Graaf, M.D., Cees J. van Steensel, M.D., Roelof
U. Boelhouwer, M.D., Geert-Jan Clevers, M.D.,
Willem S. Meijer, M.D., Laurents P.S. Stassen,
M.D., Johannes P. Vente, M.D., Wibo F. Weidema,
M.D., Augustinus J.P. Schrijvers, Ph.D., and Theo
J.M.V. van Vroonhoven, M.D.

• Multicenter randomized prospective trial
• Sample 487 (TEP-mesh) 507 (open-no mesh)
• Postop f/u 1 6 weeks, 6 mo, 1 2 years

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Conclusion

• Patients with inguinal hernias who undergo
  laparoscopic repair recover more rapidly and have
  fewer recurrences than those who undergo open
  surgical repair

Liem et al. Comparison of Conventional Anterior
Surgery and Laparoscopic Surgery for
Inguinal-Hernia Repair. NEJM. 1997. 336.
1541-7.
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Open Mesh versus Laparoscopic Mesh Repair of
Inguinal Hernia Leigh Neumayer, M.D., Anita
Giobbie-Hurder, M.S., Olga Jonasson, M.D., Robert
Fitzgibbons, Jr., M.D., Dorothy Dunlop, Ph.D.,
James Gibbs, Ph.D., Domenic Reda, Ph.D., William
Henderson, Ph.D., for the Veterans Affairs
Cooperative Studies Program 456 Investigators

• VA Multicenter randomized prospective study
• N 3518 (eligible) ? 2164 (randomization) ?
• 1983 (surgery) ? 1696 (2 yr f/u)

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Conclusions

• Higher recurrences in laparoscopic group for
  primary (same for recurrence repairs)
• Increased intra-op/postop complications in the
  laparoscopic group
• Earlier return to usual activities in lap. Group
• Recurrence rates for lap surgeons threshold was
  250 repairs

Leigh Neumayer, M.D Open Mesh versus Laparoscopic
Mesh Repair of Inguinal Hernia. NEJM. 2004
3501819-27
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Limitations

• VA population
• Variability among surgeons performance
• Surgeons experience was self-reported

Leigh Neumayer, M.D Open Mesh versus Laparoscopic
Mesh Repair of Inguinal Hernia. NEJM. 2004
3501819-27