In our own practice, we concur with the EHS recommendations and offer either an open Lichtenstein approach or laparoscopic total extraperitoneal repair for primary inguinal her­nias. Patients are routinely counseled that both of these techniques have similar excellent outcomes without superiority of one technique over the other, especially with regard to the two primary outcomes of recurrence and chronic pain. Rather, each has different considerations and limitations. For patients that wish to avoid general anesthe­sia, those with increased cardiopulmonary risk, or prior lower abdominal surgery/prostatectomy, the open Lichtenstein approach minimizes the operative risk and has excellent outcomes for both unilateral and bilateral primary hernias. It is effective for all variations of inguinal hernia, but may be more challenging or require modifi cation for femoral hernias or recurrence after prior ante­rior mesh repair. For primary bilateral hernias, recurrences after prior anterior repair, females, and known femoral hernias, the relative advan­tages of a laparoscopic approach (TEP/TAPP) are discussed and commonly accepted. In cases where mesh is either contraindicated or refused, we perform a Shouldice operation.

(TAPP) and the totally extraperitoneal hernia repair (TEP) approaches.

hernia repair (TAPP) is discussed here.

Patient preference plays perhaps the greatest role in the choice of one type of repair over another; however, surgical expertise plays a key part as well. Data show that the recurrence rate drops signifi cantly as surgeons gain experience with the laparoscopic technique. The learning curve for laparoscopic hernia repair is prolonged with most estimates ranging between 50 and 75 procedures. However, when performed by an experienced surgeon (>75 repairs), hernia recur­rence is low [ 2 ]. The learning curve of TAPP groin hernia repair is longer than in open proce­dures and some studies suggest that the learning curve for TEP may be as high as 250 cases [ 3 ].

It is generally believed that TAPP is easier to teach and learn, although there is no level 1 evi­dence in the literature to support this belief.

The patient is positioned supine with both arms tucked. During the procedure, the patients are shifted in 15–20° of Trendelenburg position to improve exposure of the working area and to move the small bowel away from the area of dissection.

NOTE : Do not tack or staple the mesh below the iliopubic tract lateral to the spermatic cord and the epigastric vessels to minimize the chance of damaging nerves and vascular structures. This area contains the “triangle of pain,” which con­tains the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve, and the adjacent “triangle of doom,” which contains the external iliac artery and vein defi ned medially by the vas deferens and laterally by the spermatic vessels (Fig. 43.11 ).

Morbidity is usually low after a TAPP procedure. R. Bittner in his article, Laparoscopic transperito­neal procedure for routine repair of groin hernia, published at BJS, 2002 reported a rate of 2.6% [ 18 ].