CURRENT REVIEWS IN GASTROINTESTINAL, MINIMALLY INVASIVE, & ENDOCRINE SURGERY
Current Laparoscopic Inguinal Hernia Repair J. Scott Roth, MD, James O. Johnson, MD, Jeffrey W. Hazey, MD, and Walter E. Pofahl II, MD Department of Surgery, Brody School of Medicine, Greenville, North Carolina INTRODUCTION The inguinal hernia repair developed through advances in anatomy and technique, as did many other surgical procedures. Operations with high mortality and recurrence were the standard until the Bassini repair was popularized in 1889.1 The Bassini repair, a tissue repair that approximates the inguinal floor, served as the gold standard for herniorrhaphy until modified to the Shouldice repair.2 Both of these repairs are primary tissue repairs that may result in tension. The development of prosthetics, such as Marlex 50 and improved polypropylene, and the anatomic understanding of the weakness associated with the myopectineal orifice of Fruchaud allowed for the development of a tension-free repair of inguinal hernia defects.3 The most commonly used is the Lichtenstein repair that involves the use of polypropylene to rebuild the inguinal floor after high ligation of the hernia sac with indirect hernias and replacement into the abdominal cavity with direct hernias.4 The Lichtenstein repair is a simple operation that can be done with local anesthetic as an outpatient procedure. In fact, it was developed for the office setting. It has a recurrence rate of 1% or less, and it is not associated with the postoperative pain of a primary tissue repair and return to full activity is very rapid, often quoted at less than 5 days. It is difficult for some to imagine how a better repair could be done in the aftermath of the success of the Lichtenstein repair. However, laparoscopic techniques have brought a whole new dimension to many aspects of surgery.
HISTORY OF LAPAROSCOPIC INGUINAL HERNIA REPAIR Laparoscopy has changed the practice of General Surgery. Procedures such as the cholecystectomy are now done in much larger numbers due to the decreased morbidity associated with a laparoscopic approach. Other procedures like the appendectomy can be done effectively by either approach with similar success. The debate seen with laparoscopic inguinal hernia re-
Correspondence: Inquiries to J. Scott Roth, MD, Department of Surgery, Brody School of Medicine, 600 Moye Boulevard, Greenville, North Carolina 27834; fax: (252) 744-5775; e-mail: [email protected]
pair is unique. The Lichtenstein repair, as described above, is a very good surgical intervention. Laparoscopy would need to improve on this to be accepted as an alternative. It is important to note the timing of the initiation of laparoscopy with regard to inguinal hernia repair. Initial reporting of laparoscopic techniques during the early 1980s involved closure of the hernia sac at the neck.5 During the same time, the tension-free repairs did not yet have the long-term data of recurrence and the primary tissue repairs such as the Bassini were seen as having too high of a recurrence rate for the modern era. It should also be noted that the initial laparoscopic techniques abandoned the anatomic closure principles of the day. The inguinal floor was not rebuilt with mesh nor was the tissue approximated in the manner of Bassini. Two techniques were used initially: ligation of the hernia sac at the neck and insertion of a mesh plug.6 As one might expect with the benefit of hindsight, these repairs had unacceptably high recurrence rates.6 The technology was not advanced with regard to optics, instrumentation, or expendables such as sutures and staples. The initial reports of the Lichtenstein repair were being reported at this time, 1989, and they were excellent. Five-year follow-up showed no recurrences nor infections related to mesh.4 The laparoscopic approach to inguinal hernia repair would have to be reevaluated. Laparoscopy would have to provide benefits above those seen with the open tension-free repair. This would require advances in technology that would allow a tension-free repair to be done utilizing the principles previously developed for inguinal hernia repair. Besides the addition of technology, a new way of looking at the anatomy of the inguinal region would also need to be addressed. Two techniques for inguinal hernia repair have evolved at this time. The Transabdominal preperitoneal (TAPP) and the Total Extraperitoneal (TEP) approach. Both of these repairs involve placing a large sheet of polypropylene mesh at the myopectineal orifice in a tension-free manner to replace a defective abdominal wall. A third method was briefly used in some centers: the intraperitoneal onlay mesh technique. This method involved a transabdominal approach that also left mesh in direct contact with the bowel.7 It has fallen out of favor, despite some adequate initial results mainly due to the concept of mesh directly against bowel for apparently no good reason.
CURRENT SURGERY • © 2004 by the Association of Program Directors in Surgery Published by Elsevier Inc.
TRANSABDOMINAL PREPERITONEAL (TAPP) The TAPP method of repairing inguinal hernias was the first of the 2 major techniques used, and it is still the most common.8 It involves entering the abdominal cavity, mobilizing the peritoneum from the abdominal wall, placing a mesh prosthesis in the properitoneal space, and closing the peritoneum over the prosthetic. It is a direct descendent of the Giant Prosthesis for the Reinforcement of the Visceral Sac (GPRVS) repair in that a large piece of mesh is placed over the myopectineal orifice of Fruchaud. Further herniation does not occur due to reinforcement of the abdominal wall at all potential sites of herniation (direct, indirect, and femoral spaces). Direct hernias are reduced, and indirect hernias are either reduced or ligated, leaving the distal sac in situ. The result of this posterior repair is that the mesh is located between intraabdominal forces and the abdominal wall, instead of exterior to the abdominal wall as with open repairs. The posterior approach utilized with the TAPP procedure brought with it the necessity of understanding the anatomy of the region in a different fashion. The view through the laparoscope is one that had not been routinely seen. Anatomic regions such as the Triangle of Doom and the Triangle of Pain were quickly described as the surgeons familiarized themselves with the posterior anatomy. The Triangle of Doom, the area bordered by the medial aspect of the spermatic vessels and the vas deferens, is an essential landmark as it contains the iliac artery and vein. The Triangle of Pain is located between the iliopubic tract and the lateral aspect of the spermatic vessels and is where the lateral femoral cutaneous and genitofemoral nerve can be identified.9 Imprudent application of clips in this region is primary etiology of post- TAPP neuralgias. The TAPP repair has a complication rate of approximately 3% to 7% with the most recent series.10-12 Complications occurring most often include hematomas/seromas, neuralgias, urinary retention, and testicular pain. Neuralgias and testicular pain have been reduced with a better understanding of the involved anatomy, and hematomas/seromas and urinary retention rarely require further intervention. Recurrences are quoted at approximately 1% or less, making the laparoscopic repair as competent as the open Lichtenstein technique. Repeatedly studies have shown that multiple quality-of-life factors, such as postoperative pain, return to activity, and chronic pain, are reduced with the TAPP repair when compared with open hernia repair, that is, the Lichtenstein technique.10 However, one must be careful when interpreting the literature with regard to comparing laparoscopic and open inguinal hernia repair. Tension-free methods must be the comparison made at this time. The Bassini repair and the Shouldice repair have proven to be excellent repairs; however, there is no comparison with regard to any perioperative or long-term parameter between a tensionfree repair and a primary tissue repair. The Lichtenstein repair is the only reasonable argument against doing a laparoscopic hernia repair. 54
The TAPP repair provides a safe method to repair groin hernias. It has a 1% recurrence rate and a complication rate of less than 10% in most studies. Most of these complications require no further treatment and resolve quickly. Patients return to full activity anywhere from 3 to 14 days after the outpatient procedure. It should also be strongly considered in patients with recurrent or bilateral hernias. The major drawback to the TAPP hernia repair is that the peritoneum is violated, and with trocar placement, the possibility exists for major complication, such as bowel or vascular injury. A totally extraperitoneal approach would remove these issues and provide the benefits of laparoscopic repair.
THE TOTALLY EXTRAPERITONEAL APPROACH (TEP) The TEP hernia repair evolved as a method of utilizing laparoscopic technology and an anterior approach without violating the peritoneum.13 This is the same preperitoneal approach brought to us by Cheatle et al. Usually, the preperitoneal space is entered by an infraumbilical incision, and dissecting balloons are then utilized to expand this space under direct vision. The operation is conducted in a similar fashion to the TAPP technique without entering the peritoneal cavity. Unilateral or bilateral hernias may be repaired in this manner. Direct hernias are reduced and indirect hernias are either reduced or ligated and left in situ. The TEP hernia repair does require that patients tolerate general anesthesia, and it can be more technically difficult to teach, learn, and perform, especially in cases involving incarceration, large inguino-scrotal hernias, and patients with previous low abdominal incisions. The TEP repair has reported complications of seroma/hematoma, testicular pain/swelling, urinary retentio, and transient neuralgias.10 These have been consistently been reported at a rate of approximately 10% collectively. Data are changing rapidly in the literature with regard to these complications and their rates of occurrence. Recent studies have reported rates of complication below 10%, with virtually all of these being transient inconveniences to patients that required no further treatment.14 Recurrence rates are also similar to the Lichtenstein approach at around 1%. Parameters that differ between patients undergoing TEP and Lichtenstein repairs largely related to quality-of-life issues. Return to full activity in a recent study was shown to be 14 days quicker with the TEP than with the Lichtenstein repair.14 Utilizing a visual analog scale, postoperative pain was also found to be decreased immediately after the operation and the next morning with the TEP procedure. Both TEP and Lichtenstein patients were given bupivocaine at the end of the case and Tylenol postoperatively. Only 18% of the TEP GROUP and 19% of the Lichtenstein group required extra analgesia. The TEP hernia repair is an excellent approach to the repair of groin hernias, although it is not without criticism. The totally extraperitoneal approach is technically more difficult than either the open repair or the TAPP approach, and it may be more CURRENT SURGERY • Volume 61/Number 1 • January/February 2004
difficult to perform in both chronic and acutely incarcerated hernias. In cases of incarceration, the TAPP approach may still be the method of choice as it allows the surgeon to visualize the reduced hernia contents.17 Postoperative neuralgia after TEP has been attributed to the use of staples or tacks in the fixation of the prosthesis. However, fibrin sealant has been shown to be an effective method of mesh fixation without the need for stapling, thereby reducing the incidence of postoperative neuralgia.15 Additionally, some surgeons have advocated performing TEP hernia repair without the use of any staples or tacks. The issue of training has largely been addressed with the advent of laparoscopic trainers, which have allowed for a much faster learning curve than was previously possible, even when compared to animal training, with surgeons mastering the learning curve in approximately 30 operations.16
pending on individual surgeon preferences. The newest aspect of groin hernia repair appears to be an old concept, tailoring the best repair to benefit the patient most.
REFERENCES 1. Bassini
E. Nuovo Metodo per la Cura Radicale Dell’erniaInguinale. Padua: Prosperina; 1889.
2. Shouldice EE. The treatment of inguinal hernia. Ontario
Med Rev. 1953;1:1-14. 3. Usher FC, Cogan JE, Lowry TI. A new technique for the
repair of inguinal and incisional hernias. Arch Surg. 1960; 81:847-854. 4. Lichtenstein IL, Schulman AG, Amid PK, et al. The ten-
sion-free hernioplasty. Am J Surg. 1989;157:188-193.
CONCLUSION The concept of hernia repair is as ancient as medicine. Only recently have repairs been able to follow the accepted principles of anatomy in a tension-free manner. Even more recently, technology has provided a manner in which to do the same repairs laparoscopically. The argument remains as to whether a repair such as the Lichtenstein, which can be done with local anesthetic in an office setting with minimal complications, can be improved on. On a basic fundamental level, if surgeons often thought in this manner, the Bassini repair would still be the optimal repair. On a technical level, the laparoscopic methods have been shown to be as effective with better patient satisfaction secondary to quality-of-life issues, such as return to full activity and decreased postoperative pain. For these reasons, the cost of operations has not been discussed. It seems it would be a difficult discussion to have with a patient to say a laparoscopic procedure will likely involve less pain and a quicker return to work but costs (insurance companies and rarely patients) slightly more. Perhaps the most recent advancement with regard to inguinal hernia repair is the development of an algorithm for the well-trained surgeon that can perform open and laparoscopic repair. The repair of choice for an uncomplicated unilateral hernia remains a controversial issue. It can be fixed with an excellent result either laparoscopically or open with a Lichtenstein repair. Patients that cannot tolerate general anesthesia would benefit from an open procedure with managed local anesthesia. Bilateral inguinal hernias are repaired much more efficiently with laparoscopic repair. In fact, bilateral repair done with the TAPP method displayed no greater complications, recurrence, postoperative pain, or delay in return than with unilateral repair.18 Incarcerated hernias are treated at the surgeons’ discretion with either open or laparoscopic repairs depending on the severity of the incarceration and the surgeon’s laparoscopic skill level. Recurrent hernias are best treated with a laparoscopic procedure to avoid previously operated planes, with both TAPP and TEP being reasonable approaches deCURRENT SURGERY • Volume 61/Number 1 • January/February 2004
5. Ger R. The management of certain abdominal herniae by
intraabdominal closure of the neck of the sac. Ann R Coll Surg Engl. 1982;64:342. 6. Schultz L, Graber J, Pietrafitta J, Hickok D. Laser laparo-
scopic herniorrhaphy: a clinical trial, preliminary results. J Laparoendosc Surg. 1990;1:41. 7. Vogt DM, Curet MJ, Pitcher DE, Martin DJ, Zucker KA.
Preliminary results of a prospective randomized trial of laparoscopic onlay vs. conventional inguinal herniorrhaphy. Am J Surg. 1995;169:84. 8. Ryberg AA, Quinn TH, Filipi CJ, Fitzgibbons RJ.
Laparoscopic herniorrhaphy: trans-abdominal preperitoneal and intraperitoneal onlay. Probl Gen Surg. 1995; 12:173. 9. Onders RP. Laparoscopic inguinal heniorrhaphy. In Cam-
eron JL, editor. Current Surgical Therapy. 7th ed. Philadelphia, PA; 2001. 10. Crawford DL, Phillips EH. Laparoscopic repair and
groin hernia surgery. Surg Clin N Amer. 1998;78:10471062. 11. Kapiris SA, Brough WA, Royston CM, O’Boyle C, Sed-
man PC. Laparoscopic Transabdominal Preperitoneal (TAPP) Hernia Repair. A 7-year two-center experience in 3017 patients. Surg Endosc. 2001;15:972-975. 12. Schultz C, Baca I, Gotzen V. Laparoscopic inguinal hernia
repair. Surg Endosc. 2001;15:582-584. 13. Wegener ME, Arregui ME. Laparoscopic totally extra-
peritoneal herniorrhaphy. 1995;12:185.
14. Bringman S, Ramel S, et al. Tension-free inguinal hernia
repair: TEP versus mesh-plug versus lichtenstein. Ann Surg. 2003;237(1):142-147. 55
15. Katkhouda N, et al. Use of fibrin sealant for prosthetic
17. Liebl BJ, et al. Laparoscopic transperitoneal hernia repair
mesh fixation in laparoscopic extraperitoneal inguinal hernia repair. Ann Surg. 2001;233(1):18-25.
of incarcerated hernias: is it feasible? Results of a prospective study. Surg Endosc. 2001;15:1179-1183.
16. Edwards CC, Bailey RW. Laparoscopic hernia repair: The
18. Schmedt CG, et al. Simultaneous bilateral laparoscopic
learning curve. Surg Laparosc Endosc Percutaneous Tech. 2000;10:149-53.
inguinal hernia repair: an analysis of 1336 consecutive cases at a single center. Surg End. 2002;16:240-244.
CURRENT SURGERY • Volume 61/Number 1 • January/February 2004