Laparoscopic Repair of Inguinal Hernias

Since laparoscopic inguinal hernia repair was first reported by Ger and colleagues in 1990 [1], the operation has been refined into an attractive alternative to open hernia repair for many patients and surgeons. Although few would argue that laparoscopic inguinal hernia repair can be performed with excellent results, controversy abounds because the results of open mesh repairs are similarly good, and the learning curve for the laparoscopic technique is long. At the center of the controversy is disagreement over whether laparoscopic and open techniques are equivalent with regard to recurrence risk, pain, and recovery. A balanced view is that both laparoscopic and open techniques play an important role in the successful management of inguinal hernia, and that the best technique for a given patient is determined more by the clinical scenario than technical factors [2]. Common clinical scenarios are discussed below.

There have been a number of well-conducted, large-scale, prospective randomized comparisons of laparoscopic versus open inguinal hernia repair for unilateral hernias published in the last decade. In the largest American trial to-date, the Veterans Affairs Cooperative Study randomized 1,983 patients to open or laparoscopic hernia repair [3]. Two-year follow-up was completed with 85% of the patients. There were twofold more recurrences (10.1% vs. 4.9%), a slightly higher complication rate (39.0% vs. 33.4%), but reduced pain and earlier return-to-work in the laparoscopic group than in the open group. This trial has been criticized because the average age of the trial participants was high, the average health-related quality of life of the participants was low, and the experience of the surgeons involved in the laparoscopic arm may not have been adequate to achieve excellent results. Another large trial from Sweden reported on 1,512 patients with unilateral hernia randomized to laparoscopic totally extraperitoneal patch (TEP) repair or open Lichtenstein repair with a 5-year follow-up [4]. Again, a higher recurrence rate was found in the TEP group (3.5% vs. 1.2%). The patients of one of the laparoscopic surgeons in the trial were found to have an unusually high risk of recurrence, but even after exclusion of that surgeon’s patients from the analysis, the recurrence risk was still 2.4% in the TEP group.

Other well-conducted trials have reported different results, thus fueling the controversy. Wright et al. [5] randomized 300 patients to TEP or open repair and reported similar recurrence rates (2%) in both arms, and similar rates of chronic pain. Johansson et al. [6] randomized 613 patients to laparoscopic transabdominal preperitoneal (TAPP) hernia repair or open repair. TAPP was associated with a 6-day-faster full recovery, a 3-day-earlier return to work, and significantly less restriction on physical activities at 7 days without any significant increase in recurrences. A Cochrane meta-analysis reviewed 41 trials of laparoscopic versus open inguinal hernia repair involving 7,161 patients [7]. The analysis found that operative times were longer for laparoscopic repairs by 15 min, and there was a higher risk of rare serious complications. Return to usual activities was faster, and there was less persistent pain and numbness. There was no significant difference in hernia recurrence rates between laparoscopic and open mesh techniques.

In summary, for the patients with a straightforward, unilateral, first-time hernia, both open mesh and laparoscopic mesh repairs offer excellent results and the choice depends upon surgeon experience and patient preference.

Outcomes for repair of recurrent inguinal hernia have been evaluated in several large-scale studies. The largest of these was a Danish study of hernia registry patients with recurrence after Lichtenstein repair [8]. The operative re-recurrence rate was 11.3% when a second Lichtenstein repair was performed, but only 1.3% when a laparoscopic repair was performed. The laparoscopic approach was better whether the original repair technique was a tissue-only repair (including Bassini, McVay, and Shouldice repairs), an anterior non-Lichtenstein repair with mesh, or even a primary laparoscopic repair.

Other prospective randomized trials have shown that the laparoscopic approach is better for recurrent hernias. One study randomized 147 patients with recurrent inguinal hernia to either open Lichtenstein or laparoscopic transabdominal preperitoneal (TAPP) repair [9]. The study reported less postoperative pain and fewer days for sick leave with TAPP. Recurrence rates were similar. A second randomized comparison in 235 patients showed fewer complications (4.4% vs. 12.2%) and fewer recurrences (2.2% vs. 5.7%) with the laparoscopic approach [10]. A third study randomized 99 patients with recurrent inguinal hernia to either open Lichtenstein or totally extraperitoneal preperitoneal (TEP) laparoscopic repair and showed less chronic pain, earlier return to work, and a trend toward fewer recurrences (0 vs. 3) [11]. Finally, in subset analysis of the Veterans Affairs Cooperative Trial, 9.3% of participants enrolled with recurrent hernia. The 2-year re-recurrence rate was 10% in the laparoscopic group, which was identical to the recurrence rate for primary laparoscopic repairs. By comparison, the re-recurrence rate was 14% in the open group, more than three times the recurrence rate (4%) observed for primary open repairs [3].

For recurrent hernias, laparoscopy offers several advantages. First, it bypasses the need to dissect in scarred tissue planes, thereby avoiding the 3-5% risk of orchitis and testicular atrophy associated with redo open procedures. Second, there is less risk of chronic inguinodynia and recovery time is shorter. Third, laparoscopy makes it possible to see the myopectineal orifice and better identify femoral hernias, which account for 9% of recurrent hernias. It also allows for mesh to be placed easily over the entire myopectineal orifice. Finally, when the diagnosis of recurrent hernia is uncertain, diagnostic laparoscopy provides a definitive diagnosis and an opportunity to repair the hernia at the same time. This avoids a groin incision and subsequent risk of wound complication [12].

A major benefit of the laparoscopic technique is for patients who present with bilateral inguinal hernias. Laparoscopy allows for both hernias to be repaired in a single operation without need for additional ports or incisions. As a result, recovery time is similar to unilateral laparoscopic hernia repair. Wauschkuhn et al. [13] reviewed 2,880 patients with bilateral hernias repaired by TAPP and compared them to 7,240 patients with unilateral TAPP repairs. Pain, disability, recovery, reoperation, and recurrence rates were similar between the two groups. Feliu et al. [14] performed a prospective controlled trial of TEP versus bilateral Lichtenstein repair with 3-year follow-up. There were threefold more complications in the patients who underwent bilateral Lichtenstein repairs (16% vs. 5%) and twice the average length of stay (1.3 vs. 0.6 days). Recurrence rates were similar.

Some surgeons believe women should undergo laparoscopic repair for all direct and indirect inguinal hernias, since synchronous femoral hernias are found in up to 40% of cases and are frequently missed. Other good candidates for laparoscopy are patients who engage in intense physical activity, such as professional athletes, since laparoscopy avoids dividing the aponeurosis of the external oblique and minimizes scar tissue between muscle planes.

An open approach using local anesthesia should be performed when the patient’s medical condition makes general anesthesia risky. Patients with prior or planned pelvic operations (for instance, radical retropubic prostatectomy) or pelvic irradiation should undergo open repair. Patients with recurrence from a prior laparoscopic repair usually should undergo open repair, although good results with a TAPP approach have been reported. Finally, patients with a strangulated hernia should undergo open repair because laparoscopic repair is more dangerous, and a primary sutured hernia repair without mesh may be necessary if the field is contaminated. Incarcerated hernia is a relative contraindication because traction on the intestines risks injury and contamination of an otherwise sterile field.

The operative steps to perform TEP and TAPP repairs are similar and have been described elsewhere [2, 15]. A detailed description of both techniques is provided below.

For patients with recurrent inguinal hernia, or bilateral inguinal hernia, or for women, laparoscopic repair offers significant advantages over open techniques with regard to recurrence risk, pain, and recovery. For unilateral first-time hernias, either laparoscopic or open repair with mesh can offer excellent results. The major drawback of laparoscopy is that the technique requires a significant number of cases to master. For surgeons in group practice, it makes sense to have one surgeon in the group perform laparoscopic repairs, so that experience can be concentrated. For others, the best technique remains the approach that the surgeon is most comfortable and experienced performing.