Laparoscopic Repair of Inguinal

Hernia – Is it really needed

The history of hernia, one of the most
beautiful chapters in the triumphs of
anatomy & surgery, is replete with ideas
& realities, myths & facts, transmutations
& shadows
• The history of hernia in toto is as old as
human race

• After centuries of much success & much

failure, we note that every period
opened avenues for a better
understanding (Raff J. Hernia healers, Ann Med History
1932;4:377)
 Ancient times
• Doctors in Iraq (Area between Euphrates &
Tigris rivers) new about herniotomy around
4000 BC
• Ancient Hindu surgeons treated hernia by
severing the sac by cautery
• Heliodorus was first to perform the hernia
surgery scientifically, separated sac from cord
• Celsus wrote about hernias in his 7th book out
of his 8 books De Medicina
 Middle ages
• Orbacius performed herniotomies in the 4th
century
• Paul of Aegina described words enterocele,
epiplocele & hydroenteroepiplocele (7th century)
• William Salicet in 13th century double ligation &
division of sac – used knife not cautery & said All
is owed to Nature – the doctor is merely her
servant also recommended that testis should not
be removed “as some stupid & ignorant doctors
do”
 The Renaissance
• In 16th century Casper Stromayr & Lindon
produce colored illustration to demonstrate
operation for cure of hernia.
• Ambroise Pare advocated the use of truss
• Lorenz Heister differentiated direct from
indirect hernia (1683-1758). He stressed the
need for a “surgeon to have complete or at least very
good knowledge in anatomy & in medicine so that he has
enough judgement & understanding to study the causes & to
draw his conclusions”
Hernia trusses
 Eighteenth century
• Better information of anatomy
• Antonio Scarpa (1752-1832)
• Albert von Haller (1708-1777) Congenital hernia
• Percival Pott anatomy of congenital hernia
• Pieter Camper (1722-89)- Camper’s fascia
• John Hunter (1728-93) – presence of process
vaginalis & gubernaculum testis
• Franz Hesselbach (1759-1816) Hesselbach’s triangle
Sir Astley Cooper (1768-1841)

• “No disease of the human body

belonging to the province of the
surgeon, requires in its
treatment a greater
combination of accurate
anatomical knowledge, with
surgical skill, than hernia in its
all varieties”
• He described Cooper’s ligament,
cremasteric fascia & fascia
transversalis
 Nineteenth century
• Space of Retzius 1858
• Space of Bogros – 1823
• Georg Lotheissen used cooper’s ligament
for repair
Edoardo Bassini (1844-1924)
• Father of modern herniorrhaphy
• Ligated & resected the sac
• First to present to world this
technique
• major contributions was that he
performed adequate audit and
follow-up of patients
• All modern modifications of
hernia repair spring from the
original Bassini repair
 Twentieth century
• Several innovations
• Marcy
• Cheatle - First to describe pre peritoneal
approach
• Prosthesis
• Nyhus
E. Shouldice (1891-1965)

• Repaired with
overlapping layers
with continuous
sutures
• Recurrence rate less
than 1%
 Lichtenstein Repair
• Tension free repair
• Use of prosthetic graft
 After Bassini’s repair
• 81 Inguinal

• 79 femoral operative techniques described

• A decade later we must humbly remember

that despite the latest successes in repair we
are in shadows awaiting Theseus.
Myopectineal orifice of Fruchaud
• Inguinal hernia repair is one of the most common
operations performed by general surgeons, with
approximately 750,000 operations done per year
in the United States by surgeons who incorporate
it as a part of their varied practices.
• Conventional open repairs without prosthetics
are most often successful for small hernias.
However, they are plagued in general by a high
recurrence rates except in specialized centres
 Why so many modifications

• Recurrence
• Chronic pain
 Laparoscopic repair
• Ger in 1990
• Fitzgibbons IPOM
• Phillips - extra peritoneal repair by exposing
the myopectineal orifice of Fruchauds &
placing the polypropylene mesh between
peritoneum & the abd wall
• Arregui 1992 TAPP
• McKernan 1993 TEP
 Lap repair of Hernia
• Lap technology has been applied to the
treatment of hernia.
• Repair is performed with placement of
synthetic mesh into the pre peritoneal space.
• Many studies devoted to comparing open
tension free repair Vs lap repair.
• Improved the recurrence rate & reduced the
chances of persistent pain.
• Acceptance of this procedure has
been slow
• Performed by surgeons who are
specifically trained
• Long learning curve
 Specific indication
• Recurrence from prior open inguinal
hernia surgery
• Bilateral inguinal hernia repair
• When diagnosis is uncertain specially in
obese pts
• Pts who are eager to return to normal
physical activity early
 Contraindications
• Unfit for GA
• Strangulated hernia
• Incarceration relative contra
indication
• Severe ascitis
 Advantages
• Post operative pain is less
• Chronic persistent pain less
• Early return to work
• Recurrence TAPP .7% TEP .4%
• Shorter convalescence
 Comparison of complication rates between laparoscopic
(transabdominal preperitoneal and totally extra peritoneal) and
open mesh repair)
Investigator Laparoscopic Open

TAPP versus open mesh

Payne, et al [18] 6 (12%) 9 (18%)

Filipi, et al [19] 3 (13%) 3 (10%)

Heikkinen, et al [20] 4 (20%) 16 (89%)

Aitola, et al [21] 5 (21%) 2 (8%)

Heikkinen, et al [22] 5 (28%) 8 (40%)

Paganini, et al [23] 14 (27%) 15 (27%)

Picchio, et al [25] 14 (26%) 13 (25%)

Douek, et al [26] 13 (11%) 52 (43%)

Anadol, et al [27] 2 (8%) 2 (8%)

 TEP versus open mesh
Investigator Laparoscopic Open

Wright, et al [28] 15 (25%) 50 (83%)

Champault, et al [29] 2 (4%) 11 (30%)

Khoury, et al [31] 20 (13%) 33 (23%)

Andersson, et al [32] 7 (9%) 4 (5%)

Bringman, et al [33] 9 (10%) 21 (20%)

Colak, et al [34] 10 (13%) 11 (16%)

Lal, et al [35] 6 (24%) 3 (12%)

Eklund, et al [36] 83 (14%) 101 (16%)

 Comparison of postoperative pain between laparoscopic
(transabdominal preperitoneal and totally extraperitoneal) and
open mesh repair

Investigator In favor of laparoscopy or open

TAPP versus open mesh

Filipi, et al [19] Laparoscopy
Heikkinen, et al [20] Laparoscopy
Aitola, et al [21] Laparoscopy
Heikkinen, et al [22] No difference
Paganini, et al [23] No difference
Wellwood, et al [24] Laparoscopy
Picchio, et al [25] No difference
Anadol, et al [27] Laparoscopy
 TEP versus open mesh
Investigator In favor of laparoscopy or open
Wright, et al [28] Laparoscopy
Champault, et al [29] Laparoscopy
Heikkinen, et al [30] Laparoscopy
Khoury, et al [31] Laparoscopy
Andersson, et al [32] Laparoscopy
Bringman, et al [33] Laparoscopy
Colak, et al [34] Laparoscopy
Lal, et al [35] Laparoscopy
Eklund, et al [36] Laparoscopy
 Comparison of time to return to work between laparoscopic
(transabdominal preperitoneal and totally extraperitoneal) and
open mesh repair

Time to return to work (days)

Investigator Laparoscopic Open

Heikkinen, et al [20] 14 19

Aitola, et al [21] 7 5

Heikkinen, et al [22] 14 21

Paganini, et al [23] 15 14

Wellwood, et al [24] 21 26

Picchio, et al [25] 46 43
 TEP versus open mesh

Investigator Laparoscopic Open

Champault, et al [29] 17 35
Heikkinen, et al [30] 12 17
Khoury, et al [31] 8 15
Andersson, et al [32] 8 11
Bringman, et al [33] 5 7
Colak, et al [34] 11 15
Lal, et al [35] 13 19
Eklund, et al [36] 7 12
 Comparison of recurrence rates between laparoscopic
(transabdominal preperitoneal and totally extraperitoneal) and
open mesh repair
Investigator Laparoscopic Open
TAPP versus open mesh
Payne, et al [18] 0 0
Filipi, et al [19] 0 2 (7%)

Heikkinen, et al [20] 0 0

Aitola, et al [21] 13% 8%

Heikkinen, et al [22] 0 0

Paganini, et al [23] 2 (3.8%) 0

Wellwood, et al [24] 0 0

Douek, et al [26] 2 (2%) 3 (3%)

Anadol, et al [27] 0 0
 TEP versus open mesh
Investigator Laparoscopic Open

Champault, et al [29] 3 (6%) 1 (2%)

Heikkinen [30] 0 0

Khoury, et al [31] 3% 3%

Andersson, et al [32] 2 (3%) 0

Bringman, et al [33] 2 (2%) 0

Colak, et al [34] 2 (3%) 4 (6%)

Lal, et al [35] 0 0

Eklund, et al [36] 5 (1%) 0

 McCormack K: Cochrane systematic
review
1. Duration of operation More Mean duration 14.81 min
2. Hematoma Fewer OR= 0.72 (0.60-0.81)
3. Risk of Seroma Higher OR= 1.58 (1.20-2.08)
4. Wound infection Less OR= 0.45 (0.32-0.65)
5. Mesh (deep) infection 3 cases 1 TAAP, 1 Open, 1 Open non mesh
6.Vascular injuries Intra Op 3 cases in Laparoscopic
Post Op. 4 cases in Laparoscopic
4 cases in Open repair
7.Visceral injuries Higher 6 in Laparoscopic
1 in Open repair
8. Time to return to usual activity Shorter HR=0.56 (0.51-0.61)
9. Persisting pain Fewer OR=0.54 (046-064)
10. Persisting numbness Fewer OR=0.38 (0.28-0.49)
11. Recurrence Less Lap: 86/3138 Vs Open: 109 /3504
 Treatment of Recurrent inguinal
hernia
1. Wound infection Less

2. Time to return to usual activity Shorter

3. Recurrence Comparable

4. Persisting pain Comparable

5. Hospital stay Shorter

Overall Laparoscopic surgeries have better outcome than Open

repair

Li J et al. 2014 Am J Surg

 Alexander am Surg Clin North
Am. 2013
1. Wound infection Less

2. Recurrence Fewer

3. Persisting pain Fewer

4. Time to return to usual activity Less

Overall Laparoscopic surgeries have better outcome

than Open repair
 Other evidences
Author Type of evidence Year Conclusion
Cavazzola LT Review 2013 Lap. Better
Fabozzi RCT 2013 LVHR is better
Kaoutzanis Review 2012 Lap. is better
Vijfhuize S Open review 2012 Lap. Better
Bracale U Review 2012 Lap. Better than OHR
Bittner R Open review 2012 Lap. Better
Yang C Syst. Review & MA 2011 Lap. Better in pediatric
Sauerland S MA 2011 Lap. Better
Tong WM Open review 2011 Better in component seperation
Garcia-Vallejo L Review 2011 Lap. Better for Parastomal hernia
Patle NM Review 2010 Lap. Better in Spigelian Hernia
Wauschkunn Review 2010 Lap. Better for BL hernia repair
Karthikesalingam MA 2010 Lap. Better
Forbes SS MA 2009 Equivocal. Lap. = OHR
Midline Dissection
Lateral dissection & Second Port
Insertion
Complimentary medial dissection
Dissection of Sac
Parietalisation of cord
Mesh Deployment
 Conclusion
• Detailed anatomical knowledge, refined surgical technique,
and experience are the decisive factors in successful
treatment of inguinal hernia by laparoscopic means.
• Surgeons should be aware of indications & contra indications
for lap repair, because some hernias should have laparoscopic
repair.
• Prospective randomised trials have proven that laparoscopic
hernia repair can be performed with a low incidence of
recurrence and complications. Post operative pain and
disability is less than after anterior repair. TEP has advantage
of not violating the peritoneal cavity.
• Yes, lap repair of inguinal hernia is definitely needed and
surgeon must learn the art of offering the best available
options to his patients.