LAPAROSCOPIC INGUINAL HERNIA REPAIR

Jeffrey S. Bender, MD, FACSUniversity of Oklahoma

College of Medicine

Objectives

• Appreciate the history and evolution

• Understand the various approaches

• Have knowledge of the complications and outcomes

• Not an attempt to teach how

Inguinal Hernia – The Problem

• Very common

• Recurrence rates still as high as 15%

• Increased recognition that mesh necessary

• “Tension-free” repairs

Laparoscopic Hernia

• Second most common laparoscopic procedure

• Initial enthusiasm now tempered

• Technically more difficult than laparoscopic cholecystectomy

• Patient demand not as great

History

• First performed with clips 1979 (Ger)

• Didn’t become popular until laparoscopic cholecystectomy

• Initial series (1990) reported plug only

• Plug migration a problem: fixation

History (cont)

• Plug: recurrence rate of 25%

• Realization that patch necessary

• Recognition of defect in transversalis fascia

• Three currently used techniques

Transabdominal Preperitoneal Herniorrhaphy (TAPP)

• First reported 1991

• Closure of peritoneum required

• Easier to learn

• Risk of bowel injury

Intraperitoneal Onlay Mesh Herniorrhaphy (IPOM)

• First reported 1992

• Technically the easiest (no retro-peritoneal dissection)

• Anecdotal: adhesion of bowel to mesh

• Not a problem in only large series published

Totally Extraperitoneal Herniorrhaphy (TEPP)

• First reported 1993

• Similar to Stoppa technique

• Avoid bowel injuries

• Learning curve reportedly more difficult

Early Results

• 444 repairs in 375 patients, 1991-1994

• Mostly TEPP; single surgeon

• Recurrence rate 0.7%

• Overall complication rate 2.0%

• Two operations for SBOFieldingAust NZ J Surg, 1995

• 869 hernias in 686 patients, 1991-1992

• ¾ TAPP, ¼ IPOM, multi-institutional

• Recurrence rate 4.5%

• Overall complication rate 17.1%

• One bowel perforation, one bladder injury, one SBO

Fitzgibbons, et al.Ann Surg, 1995

Early Results

• 600 repairs in 493 patients, 1991-1994

• ½ TAPP, ½ TEPP, single institution

• Recurrence rate 1.2% (TAPP > TEPP)

• Overall complication rate 2.0%

• 3 bowel injuries, 2 bladder injuries, 1 SBO (port)Ramshaw, et al.Surg Endosc, 1996

Early Results

• Effective repair

• Probable shorter convalescence

• No long term data

• Serious complications in 2-4:1000

Summary of Early Results

Randomized Trial #1

• 487 TEPP vs. 507 open, 1994-1995

• One year follow-up

• 6 wound infections open vs. 0 in TEPP (p=0.03)

• TEPP had quicker recovery, back to work, etc.

• Recurrence: 6.0% open vs. 3.0% TEPP (p=0.05)

• 24 conversions to open operation in laparoscopic group

• 7 major hemorrhage in laparoscopic group vs. 2in open group

• Open operation not standardized (only 3% had mesh)

Liem, et al.NEJM, 1997

Randomized Trial #1

• 496 laparoscopic vs. 460 open

• One year follow-up

• Complications: 29.9% lap vs. 43.5% open (p=.001)

• Return to activity: 10 days lap vs. 14 days open (p=.004)

Randomized Trial #2

• Persistent groin pain: 28.7% lap vs. 36.7%open (p=.018)

• Recurrence: 1.9% lap vs. 0.0% open (p=.017)

• 3 major complications in laparoscopic group

MRC GroupLancet, 1999

Randomized Trial #2

• 989 laparoscopic (90% TEPP) vs. 994 open, 1999-2001

• Two year follow-up

• Complications: 39.0% lap vs. 33.4% open

• 2 port site hernias, 2 major bleeds in laparoscopic group

Randomized Trial #3

• 3 deaths in laparoscopic group (1 bowel injury)

• 1 death in open group

• Return to activity: 4 days lap vs. 5 days open

• Laparoscopic had less pain

Randomized Trial #3

• Primary recurrence: 10.1% lap vs. 4.0% open

• Recurrent recurrence: 10.0% lap vs. 14.1% open, p=n.s.

• 250 lap hernias necessary to reduce recurrence rate

• Open recurrence rate not altered by experience

Neumayer et al.

NEJM, 2004

Randomized Trial #3

Summary

• Laparoscopic herniorrhaphy likely less painful

• Short term outcomes comparable

• Long term outcomes unknown

• Small, but real serious complication rate

• Experience is key

Current Practice

• Discuss, but don’t propose for primary

• Good option for recurrent (especially early) or bilateral

• Possible advantage in obese

• High index of suspicion for complications