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
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