1. science
2. medicine
3. surgery

Surg Clin N Am 83 (2003) 1141–1161
Laparoscopic repair for groin hernias
Chad J. Davis, MD*, Maurice E. Arregui, MD
Department of Surgery, St. Vincent Hospital and Health Center, 8402 Harcourt Road,
Suite 815, Indianapolis, IN 46260, USA
Laparoscopic inguinal herniorrhaphy was first described by Ger, Schultz,
Corbitt, and Filipi in the early 1990s [1–4] and burst upon the surgical scene
just after laparoscopic cholecystectomy. It rapidly became popular, and
many different techniques for repair were developed. Over the last decade
much good work has been done to find which type of laparoscopic repair is
best, to determine whether the laparoscopic or open approach is better, and
to develop and refine open tension-free repairs.
Twenty to 30 years ago, Doctors Robert Condon, Lloyd Nyhus, Chester
McVay, and the Shouldice Clinic surgeons stood almost alone in North
America as champions of the proper study of inguinal hernia anatomy and
repair. In the surgical community at large and in many residency programs
in particular, herniorrhaphy was regarded as a second-class operation,
relegated to the first 2 years of training. The approach in many training
programs was to repair a hernia by apposing tough ‘‘stuff to stuff.’’ Few
academic surgeons were interested in studying herniorrhaphy. That changed
with the introduction of laparoscopic hernia repair and the tension-free,
open repairs a little over a decade ago. Very quickly, hernia repair became
a topic of intense study. The last 12 years have witnessed the publication
of a large number of articles (descriptions of anatomy and technique,
retrospective reviews, randomized controlled trials, systematic reviews, and
meta-analyses), numerous meetings devoted to hernia, and the formation
of cooperative hernia study groups and hernia societies in America and
Europe and around the world. There has been no lack of energetic and
thoughtful study of the subject, and much of this interest was sparked by
the laparoscopic revolution and the constructive criticism (and sometimes
acrimonious debate) between the laparoscopic and open camps.
Open, tension-free mesh hernioplasty has also evolved and has been
incorporated into surgical practice around the world in the last 12 years.
* Corresponding author.
E-mail address: [email protected] (C. J. Davis).
0039-6109/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0039-6109(03)00122-1
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Because of its effectiveness, it has almost replaced sutured repair, so the
current question is ‘‘Which is better, laparoscopic mesh repair or open mesh
repair?’’
Despite the intense study and work devoted to laparoscopic herniorrhaphy, the penetration of this procedure into the practices of general
surgeons in the United States, Europe, and around the world remains much
less than originally projected by laparoscopic enthusiasts. It is performed
mostly by surgeons specializing in this technique, and in many cases is
limited to specific indications (bilateral or recurrent hernias). The authors
will attempt to analyze why this is the case.
Our purpose here is to summarize the work done so far and to attempt to
answer these questions: Which hernia repairs are best? What are the benefits
and drawbacks of the laparoscopic repair? Where do we stand now?
Techniques and perioperative care
Indications and contraindications for laparoscopic inguinal hernia repair
The indications for laparoscopic repair are the same as with open repair.
Contraindications (relative and absolute) include previous lower abdominal
surgery, pelvic radiation, previous extraperitoneal surgery (radical retropubic prostatectomy), and patients with impaired cardiac or pulmonary
status who are not good candidates for general anesthesia.
Anatomy
Several authors have studied and written about inguinal anatomy from
a laparoscopic perspective [5–8]. Although this anatomy was studied
previously in the development of the preperitoneal open hernia repair,
when laparoscopic herniorrhaphy was developed. These authors revisited
the subject and broke new ground in the understanding of preperitoneal
anatomy. We will not detail that anatomy here but refer the reader to the
reports listed above for further study.
Techniques of laparoscopic hernia repair
The two most common laparoscopic hernia repairs now are the transabdominal preperitoneal repair (TAPP) and the total extraperitoneal repair
(TEP). Other laparoscopic techniques, such as closure of the internal ring,
ring plasty, placement of a mesh plug and patch, and the intraperitoneal
onlay of mesh (IPOM) have largely been abandoned, at least in America and
Europe. Both the TAPP and TEP have the same basic principle of placing
a piece of mesh in the preperitoneal space as described by Stoppa [9]. The
difference is that the former requires an incision in the peritoneum to access
the preperitoneal space, whereas in the latter, dissection is initiated and
performed in the preperitoneal space. In either case, it is imperative to dissect
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the myopectineal orifice and surrounding structures completely. This means
full exposure of the pubic bone medially and the space of Retzius, ‘‘removal
of excess preperitoneal fat and cord lipomas, complete assessment of all
potential hernia sites, full reduction of the direct sac, complete dissection of
the proximal indirect sac from the cord and identification of the vas deferens
and gonadal vessels’’ [10]. What follows is a general description of the two
laparoscopic operations.
Transabdominal preperitoneal repair (TAPP)
This approach requires entry into the peritoneal cavity. The umbilical
trocar is placed and insertion of the laparoscopic allows inspection of the
inguinal area for the defect. Bilateral 5-mm trocars are placed one finger’s
breadth below the level of the umbilicus just lateral to the rectus muscle. If
a stapler is used, one of the lateral trocars needs to be 10 mm; however, 5mm spiral tackers are also available. A transverse peritoneal incision is made
from the medial umbilical ligament extending laterally to the internal ring,
just above the ring. The peritoneum and preperitoneal contents are bluntly
dissected from the anterior abdominal wall, exposing the myopectineal
orifice (the transversalis fascia). If mesh anchoring is not to be performed,
dissection should be carried across the midline for a short distance. It is also
important to dissect deep to the obturator vessels in the space of Retzius as
well as widely, laterally, and posteriorly, to provide room for a large piece of
mesh. If anchoring of mesh with staples or tacks is to be performed, a less
extensive dissection may be done. Dissection is not complete until search is
made for preperitoneal fat herniated through the internal ring (the so-called
lipoma of the cord). The authors use polypropylene mesh. If the mesh is not
anchored, it should measure 10 to 12.5 15 cm, should cross the midline
and extend into the space of Retzius, and should cover the cord structures,
extending laterally to the internal ring. It should overlap the hernia defect by
a minimum of 4 cm. If the mesh is anchored, a smaller (10 14 cm) piece
can be used. It is placed over the myopectineal orifice and anchored to
Cooper’s ligament as well as superomedially and superolaterally. Because of
the potential for nerve injury, staples or tacks should not be placed in the
inferolateral region, below the iliopubic tract. (Some surgeons make a slit in
the mesh to wrap around the cord. This can cause cord entrapment if too
tight or allow herniation through the slit if left gaping.) Once the mesh is
placed, the peritoneal defect is closed with staples or absorbable suture.
Total extraperitoneal repair (TEP)
This technique differs from the TAPP repair in that the peritoneum
remains intact during the dissection and repair. Dissection of the
preperitoneal space can be performed under direct vision (our approach)
or by using a balloon dissector. In one ‘‘direct-vision’’ approach a cutdown
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is made below the umbilicus into the preperitoneal space. The trocar is
inserted and the laparoscope is introduced through the trocar, dissecting
bluntly with the scope and insufflating with carbon dioxide to open up the
space. In contrast, our ‘‘direct-vision’’ approach is to enter the peritoneal
cavity first with a Veress needle for insufflation, then insert a 5-mm trocar
into the peritoneal space. The inguinal regions are inspected. Then, under
direct vision through a 30 angled 5-mm laparoscope, a 5-mm trocar is
placed into the lateral aspect of the preperitoneal posterior rectus space—
the space between the rectus muscle and the posterior rectus sheath
(superior to the arcuate line) or between the rectus muscle and the
peritoneum (inferior to the arcuate line). Blunt dissection is performed to
create the preperitoneal ‘‘space,’’ and the space is then insufflated with
carbon dioxide. A second 5-mm or 10-mm trocar is placed about 2 cm
inferior to the umbilicus into the preperitoneal space through which the
laparoscope is inserted. A third 5-mm trocar is placed on the contralateral
side if bilateral hernias are being repaired, or just to the other side of midline
if a unilateral hernia is being repaired. Once the preperitoneal space is
entered, wide dissection is performed as with a TAPP operation. The entire
myopectineal orifice is exposed, the hernia sac is reduced, and a search is
made for herniation of preperitoneal fat (lipoma of the cord). If the mesh is
anchored, staples or tacks are placed. If anchoring is not used, a large piece
of mesh is placed with wide overlap of the hernia defect. The mesh crosses
the midline and extends deep into the space of Retzius, widely overlaps the
internal ring, covering the vas deferens and cord structures, and extends into
the lateral inguinal space. The carbon dioxide gas is then released, taking
care that the peritoneum does not snag and roll the mesh to displace it. The
authors reinsufflate the peritoneal space, insert the laparoscope, and inspect
for mesh placement and peritoneal defects. Even though these patients are
under a general anesthetic, we spray local anesthetic into the extraperitoneal
space and infiltrate all trocar sites with 0.5% bupivicaine with epinephrine.
When the balloon dissector is used, a cutdown is made below the
umbilicus and an incision is made through the fascia on the side of the
hernia defect into the posterior rectus (preperitoneal) space, and the rectus
muscle is retracted laterally to allow blunt dissection into that space. The
balloon is then inserted and inflated in the preperitoneal space.
Postoperative care
After a stay in the recovery room, patients are observed for a short time in
the outpatient postoperative area and most are released the same day of
surgery. A mild analgesic such as propoxyfene/acetaminophen is prescribed.
Patients are restricted from driving for 2 to 3 days until nearly pain free and
off narcotic analgesics. They are encouraged to be up and about the same day
of surgery and are allowed to bathe or shower the day after surgery. Their
routine activities are not restricted.
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Fixation of mesh and use of balloon dissector
Two issues mentioned above merit further attention: (1) fixation of the
mesh with staples, and (2) use of a balloon dissector for the total extraperitoneal approach.
Fixation or anchoring of the mesh to Cooper’s ligament, the pubic bone,
and the transversalis fascia was standard practice when laparoscopic
herniorrhaphy was introduced. Then, prompted by reports of persisting
postoperative pain and nerve injuries from staples, some investigators
advocated not fixing the mesh in place [11]. This idea was bolstered by
Stoppa’s success with nonfixation of mesh in the open preperitoneal
operation [12]. If a large enough piece of mesh is placed (at least 10 15
cm), with satisfactory overlap of the hernia defect, the increase in intraabdominal pressure at the end of the operation serves to hold the mesh in
place, sandwiched between tissue layers. An interesting report from Britain
[13] showed that when nonfixed mesh was marked with clips and abdominal
films were performed at 1, 7, and 28 days, and 3 months after repair, mesh
did not migrate appreciably. One retrospective study [14] and two randomized controlled trials [15,16] have shown no difference in recurrence rates for
stapled versus nonstapled repairs. There was a trend to more neuralgia in
one study in patients in whom staples were used [14]. The debate will
continue and more investigation is needed to answer this question.
The advantage of the balloon dissector is that it may make the TEP
operation easier for the beginning surgeon and help him along the learning
curve [17,18]. It may also cut the operating time for the beginning as well as
the experienced surgeon. It costs more, however [17]. The balloon was used
in a number of the randomized trials studying TEP versus open repair, but
many investigators have performed dissection without the balloon. Few
investigators have studied this question by itself and further study may be
warranted.
Randomized controlled trials, systematic reviews, and meta-analyses
The last decade has witnessed enthusiastic investigation comparing
laparoscopic hernia repair with open repair, as evidenced by the publication of four meta-analyses [19–22], two systematic reviews [23,24], nearly
70 randomized controlled trials, and numerous retrospective reviews. The
retrospective reviews, as would be expected, mostly described the different
laparoscopic repairs and presented data supporting the feasibility of the
laparoscopic approach. That paved the way for prospective randomized
trials, which have attempted to determine how the laparoscopic and open
methods compare. The first of these was by Stoker et al from Great Britain,
published in 1994 [25]. More recently, systematic reviews and meta-analyses
have attempted to draw conclusions from the randomized trials. Our purpose
in this section is to give an overview of the literature and guide the reader
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through these studies to some meaningful, accurate, and reasonable
conclusions.
The randomized controlled trials are of varying quality. Many are poorly
designed, are underpowered (small sample size), and are made up of
heterogeneous control and study groups (open repairs including sutured as
well as mesh repairs and laparoscopic repairs including TAPP, TEP, and
onlay mesh). The difficulties these problems present in drawing conclusions
should be obvious. The easily measured endpoints, such as hernia recurrence
and operating time, are usually reported accurately, but more subjective
endpoints, such as postoperative pain and return to normal activity and
work, are not usually reported in a standard, quantified manner except in
a few instances [26,27]. Operative cost, which would seem to be a concrete,
easily measured outcome, is in fact, harder to measure than one might
expect because of the many variables that are difficult to control and the
issue of cost savings outside the hospital setting (the cost benefit of an earlier
return to normal activities and work). Although difficult, it is possible to
measure those costs, but it requires a well-designed study.
In addition to these confounding factors, open hernia repair underwent
an evolution during the 1990s from a predominantly sutured repair to
a tension-free repair with mesh. That changed the question to be answered
by hernia trials. Whereas the early trials compared laparoscopic repair with
open sutured repair, it became more appropriate by the end of the decade to
compare laparoscopic mesh repair with the open-mesh repair.
Several large multicenter randomized trials are, for the most part, welldone and provide accurate data. They warrant mention because they form the
backbone of the meta-analyses to be discussed later (Table 1). The European
Union (EU) Hernia Trialists Collaboration [19,20] has not sponsored an
independent study, but has organized the most extensive meta-analysis to
date and continues to accrue data in an effort to refine its conclusions.
Table 1
Hernia trial groups and large studies
Group/Study
Operations compared
COALA Hernia Repair Trial [30] (Conventional
Anterior versus Laparoscopic) Holland
Laparoscopic Groin Hernia Trial Group [79]
MRC (Medical Research Council) Britain
SCUR Hernia Repair Study [80] Sweden
EU hernia Trialists Collaboration [19,20]
(70 surgeons, 20 countries)
Berndsen, et al [81] Sweden
Khoury [82] Canada
Bringman, et al [83] Sweden
TEP vs. open sutured
TAPP/TEP vs. open mesh
TAPP vs. open, preperitoneal
Meta-analysis. Various types of repairs
TAPP vs. Shouldice
TEP vs. mesh-plug
TEP vs. mesh-plug vs. Lichtenstein
Abbreviation: COALA, conventional anterior laparoscopic.
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In regard to meta-analyses and systematic reviews, it should be
mentioned that there are advantages and disadvantages to performing these
studies. Meta-analyses are criticized for lumping together data from studies
of disparate study design, populations, methodology, and statistical quality,
therefore leading to invalid conclusions. If well-done, however, they can
first, provide data for accurate conclusions because of the increased ‘‘statistical power of the analysis as well as the precision of the estimate of the
treatment effects’’ [28], and second, provide information for the design of
further studies. In addition, they have the practical advantage of combining
and summarizing the results of numerous pertinent investigations into one
paper so the practicing clinician does not have ‘‘to retrieve, evaluate and
synthesize the results of all studies on the topic’’ [29]. Systematic reviews are
less rigorous in their statistical analysis, but can provide a similar benefit. To
their credit, the authors of the reviews and meta-analyses on laparoscopic
herniorrhaphy have been careful not to overstate their conclusions.
The first systematic review, by Cheek et al in 1998 [23], evaluated a variety
of hernia studies, both retrospective and randomized prospective. Because
of the heterogeneity of the groups studied, the diversity of study designs,
and the generally poor methodological quality of the studies reviewed,
conclusions were difficult to draw. This paper is most useful as a
comprehensive review of the literature up to 1998 and as a guide for which
open and laparoscopic studies to that date are of good quality.
The first meta-analysis in 1999 by Chung and Rowland of Canada [21]
included 14 randomized controlled trials. They combined data on operation length, postoperative pain, time to recovery, and hernia recurrence.
Complications and costs were not addressed. Their statistical analysis was
strong and their inclusion/exclusion criteria were clear and appeared to be
followed closely by the reviewers. Their statistical analysis was strengthened
by analyzing the data both with and without one of the large studies (a
sensitivity analysis) [30] to see if the exclusion of those data effected the
results. Exclusion of that study, which was 5 to 9 times as large as the
smaller trials, made no difference in the results. Their conclusions were that
the laparoscopic repair takes longer and costs more but that patients have
less pain and return to work faster. Recurrence rates are similar.
The meta-analysis by Voyles et al [22] deserves some attention, because
although it is titled a meta-analysis, its statistical methods and reporting of
data do not meet the criteria for a meta-analysis [28]. Under the heading
of ‘‘Methods’’ no information is given on statistical analysis or how they
addressed publication bias. In the ‘‘Results’’ section there are no tables of
results for each study and there is no mention of negative findings, but
merely a listing of P values, the source of which is not clear. There are no
statistics on operative complications. Their conclusion, that an open hernia
repair using a preperitoneal mesh prosthesis is ‘‘the optimal hernia repair’’
(which may actually be the case in many situations), does not seem directly
supported by the data.
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The most extensive systematic review [24] and meta-analysis [19,20] of
randomized controlled trials so far are those produced by the EU Hernia
Trialists Collaboration. This group is a consortium of 70 investigators from
20 countries whose purpose is to analyze data from randomized controlled
trials and report it in meta-analysis form. Data from future studies are to be
included and analyzed as they are published.
The group’s systematic review of 2000 [24] identified 34 eligible trials.
Recurrence data was accurate in most of the studies and as a consequence
could be analyzed and reported in a meta-analysis format. Recurrence rates
were not significantly different between the laparoscopic and open methods.
Data on other endpoints (return to work, postoperative pain, and so forth)
were either absent or so poorly reported that they could not be meta-analyzed.
For their meta-analysis, reported in 2002 [19,20], the group was able to
obtain individual patient data for 4165 patients in 25 trials and reanalyze it
using meta-analysis methods. This was a marked improvement over their
systematic review. Inclusion/exclusion criteria were excellent; there were two
reviewers for each study and if there was disagreement on a point, a third
reviewer arbitrated; and type of open hernia repair was controlled as best as
possible by dividing the comparisons into the following categories:
TAPP versus mesh
TAPP versus nonmesh
TAPP versus mixed open
TEP versus mesh
TEP versus nonmesh
TEP versus mixed open
This allowed comparison of more homogeneous groups. There was good
statistical analysis of principal outcomes (recurrence, operative time). Fewer
studies met the criteria to be included in analysis of persisting pain (lasting
at least a year) and return to normal activities. Cost data were not analyzed.
Data was reported in standardized meta-analysis format. The conclusions:
(1) return to normal activity is faster after laparoscopic repair, (2) persistent
pain is reduced after laparoscopic repair, and (3) the recurrence rate is lower
for laparoscopic mesh repair versus open nonmesh repair but is the same for
laparoscopic repair versus open-mesh repair. One large Swedish trial is
unreported and recruitment to another in the United States is ongoing. It
is uncertain whether the addition of these studies will result in new
conclusions.
Four issues not studied in depth in the above analyses should be
mentioned because of their potential impact on the future of laparoscopic
herniorrhaphy. The first of these is costs, which will be covered in a later
section. The second is the laparoscopic repair of bilateral hernias and the
third is the repair of recurrent hernias—two situations in which the laparoscopic approach may be advantageous. The fourth is the learning curve
for laparoscopic herniorrhaphy.
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Laparoscopic repair of bilateral hernias makes sense because the patient
has three small incisions instead of two large ones. Bilateral repairs received
passing attention in early studies, which reported them as part of an analysis
of unilateral hernia repair [31–34]. Subsequent investigators have focused on
bilateral inguinal hernioplasty alone in both nonrandomized [35–38] and
randomized [39] trials. Early results showed some high recurrence rates, but
these may have been due to surgeon inexperience or mesh that was too small
[32,37]. One recent large study of 1336 bilateral TAPP repairs, placing two
pieces of mesh fixed to the structures of the myopectineal orifice, reported
a recurrence rate of 0.6% with a median follow-up of 24 months (range, 1–84
months) [38]. The only randomized controlled trial investigating bilateral
inguinal hernias compared the TAPP procedure (with placement of a single
large ‘‘bikini mesh’’) with an open Lichtenstein repair [39]. The study was
small (43 patients) but had no recurrences for the laparoscopic group.
Results favored the laparoscopic repair for postoperative comfort and return
to work. (Several authors have suggested that one advantage of laparoscopic
repair is the ability to diagnose a clinically occult hernia on the contralateral
side and repair it at the same time [40–42]. The incidence of unsuspected
hernias was 20%–50% in these reports.) In summary, it appears that the
laparoscopic repair of bilateral hernias is feasible and may be desirable.
Laparoscopic repair of recurrent hernias, first operated on anteriorly, also
seems to make intuitive sense. First, the surgeon is dissecting through virgin
tissue instead of old scar, and second, it is argued by some that in repairing
recurrent hernias, for which there is a high subsequent recurrence rate, one
does not want to miss additional defects [43]. Therefore assessment of the
entire myopectineal orifice is crucial. The laparoscopic repair can be done
with low recurrence rates (0%–1.1%) [43–47], and several studies reported
less pain and faster convalescence [44,48,49]. Other authors, however, have
reported higher recurrence rates of 5% to 20% [50–52]. The only randomized
controlled trial showed a 12.5% recurrence rate for the TAPP repair [52]. It
appears that laparoscopic repair of recurrent hernias can be done safely and
with few recurrences, but clearly further study is necessary to determine its
effectiveness compared with open methods of repair.
Lastly, the learning curve for both TAPP and TEP is well-recognized and
its steepness has been a point of criticism from several quarters. Some
investigators have addressed the subject and shown that as the surgeon
becomes more experienced, operating times, conversions to an open procedure, complications, and recurrences all decrease [17,53–56]. It is not
known precisely how many operations are required to attain proficiency, but
30 to 50 appears to be the range [17,54–56].
Recurrences
What is the recurrence rate for laparoscopic inguinal herniorrhaphy and
what are the reasons for recurrence?
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As could be expected, before refinement of techniques and before much
experience was gained, some early investigations reported high recurrence
rates. Two early studies from 1994, one a multicenter review [57] and the
other a single-institution review by Schultz [58], reported 22% and 26%
recurrence rates respectively for the laparoscopic mesh plug technique. The
TAPP and TEP repairs faired much better, with recurrence rates of 0.7%
and 0.4% respectively [57]. A review of 23 noncomparative trails of
laparoscopic hernioplasty from 1992 to 1995, all with 100 or more patients,
showed recurrence rates ranging from 0% to 4.5% [50]. Fifteen of the 23
studies in that review followed their patients at least 1 year and 6 of them
followed their patients for more than 2 years. This is felt to be adequate
follow-up, as Stoppa showed that all of his recurrences using the open
preperitoneal technique occurred within the first year and were thought to
be due to technical error.
As for the mechanisms of recurrence, these are listed by numerous
authors [10,57,59–61] and are summarized in Box 1 below. They are almost
all technical problems. As techniques have evolved and improved,
recurrence rates have fallen. Likewise, as the technician (the surgeon), has
improved, so have his results.
The two most common causes of recurrence are incomplete dissection of
the myopectineal orifice and inadequate size of the mesh. Lowham et al [10]
reviewed 13 videotapes of hernias that had recurred in the multicenter trial
by Fitzgibbons et al [62] and found that incomplete dissection of the
myopectineal orifice was the primary cause of recurrence. There were other
causes also, but in many cases they were secondary to inadequate dissection.
It should be obvious that incomplete dissection leads to missed hernias
(direct or indirect) as well as to missed lipomas (herniated preperitoneal fat).
Lilly and Arregui [63], Gersin et al [64], and Felix et al [59] have all pointed
out that a missed lipoma may be a significant factor in recurrence and should
be searched for in every case. Absence of a peritoneal sac at laparoscopic
inspection, especially during a TAPP repair, does not exclude a herniation of
preperitoneal fat [64]. Inadequate reduction of a direct hernia sac and
inadequate dissection of a proximal indirect sac from the spermatic cord also
fall under the heading of incomplete dissection and should be attended to
before placing the mesh. Rolling of the edges or corners of the mesh is a result
of inadequate dissection, because a space too small to accommodate the
mesh leads to mesh buckling and therefore rolling of the edges of the mesh.
Small mesh leads to inadequate overlap of the defect—overlap should be
at least 2 cm if mesh is stapled and 3 cm to 4 cm if not stapled. It also can
result in migration of the mesh, and in some cases, rolling of the mesh
[57,60,64]. Shrinkage of mesh is a recognized phenomenon and is a bigger
problem the smaller the mesh [10]. The average prosthesis size in patients
with recurrence was 6.5 cm 9.6 cm in the multicenter trial by Fitzgibbons
et al [62]. Subsequent investigations showed that the mesh should be at least
10 cm 14 cm in cases where the mesh is fixed and 10 to 15 cm 15 cm
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Box 1. Causes of recurrence
Evolution of technique
Inexperience (learning curve)
Incomplete dissection
Missed hernia
Missed lipoma (herniated preperitoneal fat) of cord or of
direct hernia
Inadequate reduction of direct hernia sac
Inadequate dissection of proximal indirect sac from cord
Rolling of mesh
Mesh size and configuration
Too small
Inadequate overlap of defect
Migration
Configuration (slit or keyhole)
Mesh fixation
Mesh poorly fixed laterally
Mesh poorly fixed medially
Clips pulled through
Mesh never stapled
Issue of mesh fixation versus nonfixation
Mesh displacement
Hematoma
Seroma
Migration
Rolling of mesh
Shrinkage
where the mesh is not fixed [31,65]. Some surgeons cut a slit or keyhole in
the mesh to better fit the mesh around the gonadal vessels and vas, but this
has been found to lead to herniation of the cut mesh through the internal
ring or to herniation of preperitoneal fat if the slit is made too large.
As mentioned earlier, fixation of the mesh is now a debatable issue, as
at least two randomized controlled trials show no difference in recurrence
rates for fixation versus nonfixation [15,16]. Other authors [10,57,59–62],
however, focus on the lack of fixation or improper fixation as a major cause
of recurrence and emphasize correct methods of fixation. (In some of these
studies, recurrence may have been caused by the use of smaller mesh.) It
appears that the vast majority of trials so far have used mesh fixation, but
the question remains to be answered.
Finally, displacement of mesh by a hematoma or seroma is mentioned by
some as a cause of recurrence in a small number of patients. This may be
due to technique (rough dissection or inadequate fixation of mesh) but may
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also be one of the only factors that in some cases is out of the control of the
surgeon (ie, patients with a coagulopathy, fragile tissues, bad luck).
Complications
Numerous authors have studied the complications of laparoscopic
herniorrhaphy either as the primary focus of their analysis or as a major
part of their investigation of laparoscopic hernia repair [38,57,62,66,67].
Complication rates vary from 3.8% to 13.6%. Some investigators divide
their complication results into intraoperative and postoperative categories
[57,62], or by the different types of repair (ie, TAPP, TEP, IPOM, plug and
patch, ring closure) [57,66]. This has helped sort out where problems exist in
the performance of a particular type of repair, and has helped determine
which hernia repairs have unacceptably high recurrence or complication
rates (laparoscopic plug and patch).
Laparoscopic herniorrhaphy shares some complications with the open
technique but also has its own set of complications. Some of these problems
were encountered early on and were corrected as surgeons became more
experienced with the technique. Thus, the incidence of complications has
decreased with time [62,67]. In an interesting analysis of their experience,
Felix et al found a 2.7% complication rate over a 6-year period, but when
the data was broken down into two 3-year periods, their complication rate
of 5.6% for the first 3 years dropped to 0.5% in the second 3 years. They
also found that 90% of the complications occurred in the first 50% of
patients [67]. In a similar vein, Fitzgibbons et al looked at postoperative
neuralgia and found that leg pain decreased significantly (from 7% to 1.8%)
after surgeons performed 30 cases. Postoperative groin pain remained
steady at about 8% and testicular pain at 2% [62].
Complications from laparoscopic herniorrhaphy can be categorized into
those that occur intraoperatively (Box 2 below) and those that occur
postoperatively (Box 3 below). Complications related to the laparoscopic
technique itself, or to the hernia repair, include vascular injuries or injuries
to bowel. A number of early studies [19,20] showed a higher rate of these
injuries, especially with the TAPP repair, but the incidence decreased with
time and with a change in some centers to the TEP repair. Hypercapnia (and
its related problems—subcutaneous emphysema, pneumomediastinum) is
a complication of laparoscopy and is often out of the surgeon’s control. It
is associated more with the extraperitoneal approach than with other
approaches. Lower insufflation pressures may help prevent it.
The majority of complications are postoperative. Urinary retention,
a complication of open repair as well, was the most common of the patientrelated problems, with an incidence of 1.3% to 5.8% [57,62,66]. Tetik et al
and others found a high incidence of hematomas and surmised that it was
due to the more extensive dissection performed with the TAPP and TEP
repairs [57]. Some, however, have found a lower incidence [19,20]. Chronic
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1153
Box 2. Intraoperative complications
Related to laparoscopic technique
Trocar injury to bowel, bladder
Trocar site hemorrhage
Abdominal wall hematoma
Hypercapnia
Subcutaneous emphysema
Pneumomediastinum
Pneumothorax
Related to laparoscopic hernia repair
Vascular injury
Femoral vessels
Epigastric vessels
Gonadal vessels
Nerve entrapment (stapling, tacking)
Transection of vas deferens
Transection of nerve(s)
groin pain or neuralgia, both of the ilioinguinal nerve and the lateral
cutaneous nerve of the thigh, occurred with an incidence of 0.5% to 4.6%
and depended on the technique of repair. The IPOM method had the highest
incidence of neuralgia in one study [62], and that, among other reasons, led
to its abandonment as a viable repair. As surgeons have become more
knowledgeable of the nerve anatomy from the abdominal perspective, the
incidence of neuralgia has decreased. Testicular problems include pain,
swelling, and orchitis, and occur in 0.9% to 1.5% of cases. Most are
transient. Orchitis was found in a small number of patients but did not lead
to testicular atrophy [57,62,66]. Clinically significant trocar site hernias,
leading to small-bowel obstruction and mesh complications, occurred early
in the experience and have decreased in incidence. Likewise, as surgeons
became more meticulous about peritoneal closure (in the TAPP repair) or
switched to the extraperitoneal repair, the incidence of small-bowel obstruction from that etiology decreased.
Phillips et al pointed out that to put these complication rates in
perspective they must be compared with complication rates for open repairs.
If that is done, one finds that the laparoscopic repair compares favorably
with the open repair in a number of areas—vascular injuries, testicular
problems, seromas, and hydrocele [66]. Notably, the EU Hernia Trialists
meta-analysis found no difference in the complication rates of laparoscopic
versus open repair [19,20]. Therefore, despite some early problems and
complications unique to the operation, the laparoscopic repair has proven
itself a safe procedure in the hands of experienced surgeons.
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Box 3. Postoperative complications
Related to the patient
Urinary retention
Others (MI, PE, DVT, etc.)
Related to the hernia repair
Seroma
Hematoma
Hydrocele
Neuralgias
Nerve entrapment (staple)
Nerve injury
Ilioinguinal
Lateral cutaneous nerve
Groin pain
Early (transient)
Late (chronic)
Testicular problems
Pain
Swelling
Orchitis
Trocar site hernia with secondary:
Small bowel obstruction
Incarcerated omentum
Small-bowel obstruction from peritoneal hole
Wound infection
Mesh complications
Infection
Late rejection
Costs—laparoscopic versus open repair
Cost analyses comparing laparoscopic with open techniques of hernia
repair are difficult to design and sometimes hard to interpret. Nevertheless,
in the current environment it is important to consider cost when deciding
which herniorrhaphy to perform. As a consequence, cost studies are vital in
providing that information to practitioners. There have been several strong
studies to date and it is impossible to do justice here to the complexities of
their cost calculations and analyses; however, it is possible to draw some
general conclusions.
First, it is necessary to discuss the difficulties in determining hospital costs
for herniorrhaphy. Hammond and Arregui [68] point out that one is not only
dealing with known, direct costs but also hidden, indirect costs (administrative, facility and equipment depreciation, and so forth), enigmatic hospital
C.J. Davis, M.E. Arregui / Surg Clin N Am 83 (2003) 1141–1161
1155
accounting practices, and arbitrarily marked up charges for disposable items.
Rutkow writes about the breakdown of costs into fixed overhead (rent,
salaries, equipment common to each operation) and soft overhead (‘‘throwaways’’ such as caps, gowns, gloves, sutures, mesh) [69]. Several investigators
have addressed these issues with some success. In addition, they have
attempted the complex task of calculating the cost to society, in days missed
from productive work, to determine if the shorter recovery for laparoscopic
repair is enough to compensate for its higher costs. The results, although
widely divergent, seem to favor the laparoscopic repair, as shown in Table 2.
Evaluation of cost analyses for hernia repair includes many issues, but
the most important are: (1) the surgical technique used, especially for the
open repair; (2) adequate sample size (400–500 patients), to reduce the
influence of the many variables; (3) reporting of information on recurrences
and the cost of repairing them; (4) methods for estimating costs; (5) if
a multicenter trial, the method for controlling costs between centers; and (6)
the surgeon’s experience with the technique. Of the studies focusing
primarily on cost [70–77] the ones by Leim et al [70] and Wellwood et al
[76] have the strongest methodology. However, Wellwood et al did not
include recurrence data, which is important in determining ultimate cost,
and Liem et al compared open sutured repair with laparoscopic repair,
probably not the comparison most investigators would make today. That
might have biased the study toward the open repair, as there would be no
cost for mesh. However, their recurrence rate for the open repair was 6.1%,
versus 3.5% for the laparoscopic repair, which probably made the
laparoscopic repair less expensive in the long run because of the cost of
repairing a recurrence. Dirksen et al [75] and the Medical Research Council
trial [77] included surgeons with little experience (those with a minimum of
only 10 laparoscopic repairs to their credit), which may have lengthened the
operating time. Dirksen et al used the Bassini repair for the control group, in
which there was a high early recurrence rate. They included cost data for the
repair of recurrences, however. Heikkinen et al’s studies [72–74] were welldesigned but vastly underpowered (40–50 patients in each study). Kald et al’s
study [71] had a larger sample size (200 patients), was prospective and
Table 2
Societal cost comparisons
Societal cost savings by procedure
Study (year)
Liem (1997) [70]
Kald (1997) [71]
Heikkinen (1997) [72]
Heikkinen (1998) [73]
Heikkinen (1998) [74]
Dirksen (1998) [75]
Laparoscopic
$1364
$524
$649
$1156
$464
Open
Types of repairs
$106
TEP vs. Open sutured
TAP vs. Shouldice
TAPP vs. Lichtenstein
TEP vs. Lichtenstein
TAPP vs. Lichtenstein
TAPP/TEP vs. open mesh
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randomized, and had appropriate exclusions, but it used the Shouldice
repair for its control group and reported a 3% recurrence rate for that group
compared with no recurrences for the laparoscopic group.
Despite the shortcomings of these studies, it is interesting to note the
similarity in cost differences reported (Table 3). This difference, in most cases,
is the cost of disposable equipment and longer operating time. Swanstrom
has published one of the only detailed descriptions of a cost-cutting effort for
laparoscopic herniorrhaphy [78]. His group looked at the cost of each
component of a laparoscopic hernia repair and cut costs wherever possible.
They eliminated unnecessary items (fixation staplers, dissection balloons),
sought less expensive alternatives for necessary items (mesh, trocars, and
instruments) and pursued ways of cutting operating time. Their results
demonstrated ‘‘a steady decrease in the cost of the laparoscopic hernia
repairs, approaching and, for the bilateral repairs, bettering, the costs for
open mesh repairs’’ [78]. Our unpublished data lead to a similar conclusion.
Add to this the steadily decreasing reimbursement to surgeons in America
from Medicare over the last number of years and it becomes difficult to cover
the cost of laparoscopic herniorrhaphy (or any operation). A number of
Medicare patients (those over 65 years old) are good candidates for the
laparoscopic repair, however, and efforts such as those of Swanstrom are
needed to cut costs and make this operation a viable option for those patients.
Summary
So where do things stand in 2003? Laparoscopic herniorrhaphy appears
to result in less postoperative pain (acute and chronic) and in a shorter
convalescence and an earlier return to work, compared with the open repair.
Table 3
Cost comparisons (laparoscopic vs. open)
Study
(year)
Payne (1994) [26]
Johansson (1999) [80]
Tanphiphat (1998) [84]
Liem (1997) [70]
Kald (1997) [71]
Heikkinen (1997) [72]
Heikkinen (1998) [73]
Heikkinen (1998) [74]
Dirksen (1998) [75]
Wellwood (1998) [76]
Medical Research Council
(2001) [77]
Cost difference
(more for lap.)
$600
$830
$435
$400
$432
$483
$517
$457
$446
$300
$505
$480
Type of
Repairs
TAPP with disposables
TAPP with disposables
With reusables
TAPP vs Bassini
TEP vs. open sutured
TAP vs. Shouldice
TAPP vs. Lichtenstein
TEP vs Lichtenstein
TAPP vs Lichtenstein
TAPP vs. Bassini
TAP vs. Lichtenstein
TAPP/TEP vs. mesh
Included disposables
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1157
It can be performed safely and with a low recurrence rate. However, it takes
longer to do, is more difficult to learn, and costs more, all reasons why it is
not more commonly performed. Currently, laparoscopic herniorrhaphy
accounts for 15% to 20% of hernia operations in America and around the
world. Who can blame the surgeon in a community practice for opting for
the open mesh repair, operating on familiar anatomy, and using familiar
techniques? Nevertheless, with efforts to cut costs by eliminating disposable
equipment and honing skills to decrease operating time, laparoscopic
herniorrhaphy will probably continue to be a contender, especially for the
younger patient who wants to return to work quickly and for patients with
bilateral and recurrent hernias. It is arguable that surgeons should possess
skill in both open and laparoscopic techniques and should know the
indications for each—some hernias are best repaired laparoscopically. That
said, laparoscopic herniorrhaphy will most likely be performed by those
with a special interest and proficiency in the technique.
At the least, the laparoscopic revolution and laparoscopic hernia repair
have helped elevate the study of hernia anatomy and herniorrhaphy to
a position it deserves and this has made us all better hernia surgeons. What
was once the stepchild of general surgery now occupies a more prominent
and respectable place. With the continuing efforts of dedicated, energetic
investigators, we should continue to see advances in the safe and effective
repair of this most common of surgical maladies.
Acknowledgments
We would like to thank Mr. Mark Smith, Clinical Statistician, St.
Vincent Hospital and Health Services, for assistance with statistical analysis;
Mrs. Cindy Oakes for manuscript preparation; and Louise Haas and Denise
Rumschlag of the St. Vincent Hospital Library.
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