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31 MIS vs. Open Inguinal Hernia forUncomplicated Unilateral Hernia
431
Laparoscopic Repair
Initial reports of laparoscopic inguinal hernia repair by Ger in 1982 described using a
clip applying device to close the internal inguinal ring in dogs. Further progress in the
description of laparoscopic repair described mesh “packing” into defects laparoscopically in order to ll the defect from within the peritoneal cavity. These ultimately
failed as reinforcement of the abdominal wall was not achieved and did not address
the inherent weakness of the orice [8]. Today’s repairs are accomplished in the preperitoneal plane through either transabdominal or totally extraperitoneal approaches.
In the transabdominal preperitoneal (TAPP) approach, the peritoneal cavity is
insufated, and the preperitoneal space is entered by incising the peritoneum and
bringing down a ap. The hernia sac and its contents are reduced from within, separated from the spermatic cord (in the case of an indirect hernia), and a mesh is laid
within the preperitoneal space covering indirect, direct, and femoral hernia defects.
The peritoneal ap is then reapproximated with a tacking device or suture leaving
the mesh within the preperitoneal space.
In the totally extraperitoneal (TEP) approach, the preperitoneal space is insufated posterior to the rectus muscle and anterior to the posterior rectus sheath. This
exposes the hernia defect without violating the peritoneal cavity. Once this has been
accomplished, a similar procedure of reduction of hernia content and separation
from cord structures is undertaken, and placement of mesh is used to cover the hernia defects in the preperitoneal space.
Robotic repair of inguinal hernias has increased in popularity in recent times.
The principles of robotic repair mimic those of TAPP but offer the advantage of
robot-driven dexterity and hand-sewn peritoneal ap closure. Cost may be increased
with robot utilization, but the benet of hand-sewn peritoneal ap closure merits
consideration when choosing modality for repair. Avoidance of tacking devices may
potentially avoid chronic pain syndromes and inadvertent bladder or vascular injury
[9]. The use of self-gripping mesh or glue during these repairs may also provide less
pain and equivalently secure placement of the preperitoneal mesh [10].
Intraperitoneal onlay mesh repair (IPOM) is also described but is not used in
practice routinely given the direct interface between intraperitoneal content and
mesh, potential undersizing of the mesh, and difculty in xing the mesh appropriately. The theoretical advantage of such a repair would be to avoid dissecting in the
preperitoneal space; however, the inherent risks of IPOM repair in this area outweigh the benet of violation of preperitoneal anatomy. It should be noted, however, that should a surgeon nd themselves with inadequate peritoneum to cover a
preperitoneal mesh, there are synthetic materials (e.g., Vicryl mesh) that are suitable
for interface between prosthetic hernia mesh material and intraperitoneal viscera.
Repair vs. Watchful Waiting
Most patients with symptomatic inguinal hernias should be offered repair [11]. For
patients with asymptomatic or minimally symptomatic inguinal hernias, the answer
is less clear. Watchful waiting has been previously advised for asymptomatic or
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F. Balla and A. D. Patel
minimally symptomatic uncomplicated inguinal hernias. However, two randomized
controlled trials investigating immediate repair vs. watchful waiting show that this
strategy may simply delay the inevitable repair of a hernia secondary to pain. A UK
study showed 72% crossover rate into surgical repair at 7.5-year follow-up, and a
North American study showed 68% crossover rate into surgical repair at 10-year
follow-up [12–15]. The main symptom prompting repair in both studies was increasing pain. Furthermore, studies have shown that watchful waiting does not increase
frequency of complications from repair of larger fascial defects or progression of
associated comorbidities [16]. Emergent hernia surgery for strangulation carries
increased risk of complications, but only a total of three patients between both studies presented with incarceration. Two of those patients had their hernias reduced and
repaired electively, while the other required emergency repair. These studies also
showed that those who eventually crossed over did not experience greater complications than those in the immediate repair group. These ndings lay out benets of
both watchful waiting and immediate repair. Surgeons should discuss the risk-tobenet prole for each individual patient with an asymptomatic or minimally symptomatic hernia. While the natural course of inguinal hernia seems to be progression
to lifestyle-limiting pain in the majority of patients, there are a large number of
patients who remain asymptomatic or minimally symptomatic even at 7–10-year
follow-up [12–15]. Socioeconomic factors such as ability to return to work and cost
of repair should be considered as well. Activity restrictions with known inguinal
hernias may affect employment. In these trials, several risk factors have been shown
to predict whether or not a patient will eventually ask for surgery due to pain. These
are pain with strenuous activity, chronic constipation, married patients, patients
with prostatism, and ASA classes 1–2 [17]. Recently published clinical practice
guidelines from the New England Journal of Medicine state that “watchful waiting
is an acceptable strategy” for asymptomatic or minimally symptomatic hernias
despite the high likelihood of eventual need for surgery [11]. These guidelines are
consistent with recommendations offered by multiple other hernia societies and surgical groups [
18].
Pros andCons ofLaparoscopic vs. Open
Recurrence andtheLearning Curve
Recurrence is the single most signicant postoperative outcome after hernia repair.
The landmark Veterans Affairs Cooperative Study questioned the benets of laparoscopic repair for primary inguinal hernias as their recurrence rates were nearly double in the open TFR group [19]. When further examined, however, it was found that
surgeons who had performed more than 250 laparoscopic repairs had recurrence
rates that were not signicantly different from the open group. Furthermore, perioperative complications such as pain, seroma, and surgical site infections were similar
when stratied by surgeon experience. Thus, the utility of comparing laparoscopic
vs. open repair with this study is limited given the mixed results upon further
31 MIS vs. Open Inguinal Hernia forUncomplicated Unilateral Hernia
433
analysis. Later studies have lent credence to the idea of experience-driven results.
Langeveld etal. showed that more experience in laparoscopic inguinal hernia repair
decreases recurrence rates as well as perioperative morbidity [20]. Numerous metaanalyses have also shown similar recurrence and perioperative morbidity rates
between laparoscopic and open mesh as well as non-mesh repairs [21–25]. The
question therefore becomes “when is a surgeon experienced enough to safely perform a laparoscopic repair?” This question has been addressed for TEP repairs on
unilateral uncomplicated inguinal hernias. Suguita etal. showed in 2017 that operative time stabilized and plateaued after the 65th repair [26]. No complications were
observed in their study after the 35th repair. This study, however, had signicant
limitations in that it only studied one surgeon and had limited long-term follow-up,
and the surgeon studied had carried out advanced laparoscopic training prior to the
period studied as a rst assistant. This would seem to indicate that the true learning
curve number is likely higher than 65 patients. Laparoscopic inguinal hernia repair
is not frequently performed by surgical residents, and thus in all likelihood, graduating residents have not transcended the learning curve at graduation [27]. Using the
robot may decrease this number, but little data exists regarding the learning curve
associated with robotic inguinal hernia repair; some anecdotal information may
point to an early learning curve. One study showed that operative times are signicantly longer with robotic repair but decreased with surgeon experience [28]; more
prospective studies are needed to assess this assertion.
Pain
For both acute and chronic pain, numerous studies have shown LIH repair to be
equivalent to or better than TFR [29–33]. Chronic pain is dened as pain lasting
longer than 3months post procedure [11]. The etiology of this pain is multifactorial
but can be caused by neuropathic mechanisms, scar tissue formation, reaction to
foreign tissues, or chronic infection, among other things. Treatment with antiinammatory medications is a reasonable rst-line treatment for acute pain to lessen
the inammatory component of these etiologies. Chronic unrelenting neuropathictype pain may be treated with neurectomy or mesh excision if entrapment is the
source [11]. Of all the variables to discuss when comparing LIH to open TFR, pain
is consistently shown to be the most improved after LIH [9]. Furthermore, studies
have shown that open TFR itself was an independent risk factor for chronic pain
[31]. The European Hernia Society has stated that “when only considering chronic
pain, endoscopic surgery is superior to open mesh” [34].
Early Complications
LIH repair has a higher rate of visceral and major vascular injury intraoperatively
when compared to open. Although rare, this could present a strong point of consideration when deciding between open TFR and LIH repair. Major visceral and
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F. Balla and A. D. Patel
vascular injuries are seen more often with TAPP approach vs. TEP.Higher risk to
bowel and vasculature is inherent with TAPP given the surgical approach, but this
does not preclude TEP from such issues [35]. Other potential early complications
from TAPP repair are early bowel obstruction from adhesion to exposed mesh and
mesh dislodgement from improperly placed xation tacks. The advantage to TEP
approach is avoidance of the peritoneal space which effectively eliminates potential
bowel injury. Surgical site complications such as wound infection and hematoma
are more frequent in open TFR [21–25].
Bilaterality andRevisional Surgery
Laparoscopic approach offers the benet of visualizing both groin areas in the same
procedure, especially with TAPP.This is an advantage of laparoscopy as in 10–22%
of cases, a contralateral hernia is discovered during surgery for unilateral hernia [36,
37]. Interestingly, in up to 20% of patients, a preoperative diagnosis of bilateral
inguinal hernia was found to be incorrect, and these patients were only found to
have unilateral hernias when examined laparoscopically [38]. While simultaneous
bilateral open repair is feasible and has historically good results, laparoscopic repair
may offer the benet of decreased operative time and quicker return to daily
activities.
Previous approaches to hernia repair should inuence the surgeon’s modality of
choice for recurrent hernia repair. If the previous repair was done in the anterior
space, a laparoscopic preperitoneal approach would offer equivalent recurrence
rates in an undissected plane. If the previous approach was done in the preperitoneal
space laparoscopically, a conventional anterior open approach would offer the repair
with the lowest complication rate.
Robot
Robot-assisted repair of inguinal hernias (rTAPP) offers greater degrees of freedom
with movement and better three-dimensional visualization during repair. The ability
to work with high-resolution visualization and improved dexterity offers the ability
to perform more complex dissections. Using robotic assistance, inguinal hernias are
repaired in a similar fashion to TAPP but with the advantage of hand-sewn closure
of the peritoneal ap versus using tacks. Recent studies have shown robotic inguinal
hernia repair is safe and favorable compared to LIH repair [39]. Operative time is
longer for the robot, and there was a slight tendency toward higher intravenous narcotic use perioperatively. However, operative time decreased as surgeon’s experience increased [28]. Like LIH repair, there is a learning curve associated with
robotic inguinal hernia repair, but the exact number at which point a surgeon gains
prociency is unknown. Operative times are increased in robotic repair primarily as
a result of hand-sewn closure of the peritoneal ap. This theoretically decreases the
risk of chronic pain postoperatively as no xation tacks are being used to hold the
31 MIS vs. Open Inguinal Hernia forUncomplicated Unilateral Hernia
mesh or peritoneum in place [40]. Furthermore, the avoidance of tacking devices
limits the risk of inadvertent vascular or visceral injury. Disadvantages of the robot
include lack of tactile feedback and mainly cost [41]. With little data to support
earlier return to work or decreased postoperative pain compared to laparoscopy, the
primary advantage of robotic repair may be the ability to perform more complex
inguinal hernia repairs without conversion to open including large scrotal components or revisional procedures. It may also allow more surgeons to offer a MIS
approach as both laparoscopic TEP and TAPP can be ergonomically challenging in
certain patients. As with any new technology, however, the challenges facing the
widespread use of robotic assistance with inguinal hernia repair are the need for
high-quality data, cost-effective implementation, and transcendence of the learning
curve [41, 42]. Many of these issues will be addressed soon as many studies are currently being performed.
435
Recommendations
Watchful Waiting
Adult male with asymptomatic or minimally symptomatic unilateral inguinal
hernia
Open Repair
Large scrotal hernia or incarcerated hernia
Patient unable to tolerate general anesthesia or Trendelenburg positioning
Recurrent hernia when initial hernia performed laparoscopically
Increased risk for prostate cancer or need for future prostatectomy
Prior lower midline laparotomy
Laparoscopic or Robotic Repair
Uncomplicated unilateral hernia at high-volume center
Recurrent hernia when initial hernia performed open
Bilateral inguinal hernias
Women with inguinal hernias
Uncomplicated femoral hernia
Laparoscopic vs. Open Repair
Surgeon comfort with procedure
Patient preference
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F. Balla and A. D. Patel
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TAPP vs. TEP vs. rTAPP: What Does
theEvidence Show?
AlexandraArgiroff andDiegoCamacho
Introduction
For a growing number of hernia surgeons, laparoscopic inguinal hernia repair is the
go-to operation, even for primary unilateral hernias. It has similar recurrence and
complication rates as the open repair [1] and less postoperative pain with faster recovery time [2]. So how do you choose the appropriate minimally invasive technique?
Laparoscopic surgery for repair of inguinal hernias with mesh has been used for
over 25years, since it was rst described in 1991 by Shultz [3]. The technique originally trialed was the transabdominal preperitoneal approach or TAPP.Two years
later, a second and currently commonly used technique was described by
McKernan—the totally extraperitoneal (TEP) approach [4]. There is a plethora of
evidence describing the two operations and comparing the laparoscopic inguinal
hernia repair to the traditional open repair with mesh. The two surgical techniques,
appropriate use, complications, and comparison of laparoscopic to open inguinal
hernia repair are discussed in previous chapters in this book.
The newest minimally invasive technique, or the robotic transabdominal preperitoneal (rTAPP) inguinal hernia repair, also has a growing volume of data in the literature, albeit preliminary and descriptive in most cases. The rTAPP is discussed in
a previous chapter as well.
Once the surgeon and patient have decided to proceed with a minimally invasive
surgery to repair his or her inguinal hernia, which method is the best? Is there a clear
front-runner? Or is one technique better in a particular patient or clinical scenario?
32
A. Argiroff (*) · D. Camacho
Department of Surgery, Minimally Invasive and Laparoscopic General Surgery,
Monteore Medical Center, Bronx, NY, USA
e-mail: dicamach@monteore.org
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_32
439
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A. Argiro and D. Camacho
The aim of this chapter is to look at the current data and evidence available comparing the TEP and TAPP techniques for inguinal hernia repair with mesh, as well as a
comparison of the laparoscopic repairs to the rTAPP.
While there are several studies, including randomized controlled trials and metaanalyses, comparing open and laparoscopic inguinal hernia repairs, there is less data
directly comparing the two laparoscopic techniques. There are even fewer studies
comparing laparoscopy to the newer rTAPP.In addition to landmark papers, the
most current published data will be discussed in this chapter to see what evidence is
available to help choose the right minimally invasive technique for both the surgeon
and patient.
TEP vs. TAPP
What Type ofEvidence Is Currently Available?
First, we will present what evidence is currently published, along with overall
results from those articles. Then each end point will be examined separately with
data in support of TEP or TAPP.
While not numerous, there are several head-to-head studies between TEP and
TAPP in the literature, with signicantly more articles published in the last 10years.
The 2005 Cochrane review comparing TAPP to TEP identied one prospective randomized controlled trial (RCT) and eight comparative studies [5]. In 1996, Schrenk
etal. compared TEP, TAPP, and Shouldice technique among 86 randomized patients
[6]. They found less immediate postoperative pain in the TAPP group when compared to TEP; however, there were similar operation times, complications, and
return to work. There was one recurrence in the TAPP group, but it was not statistically signicant (p=0.6). This study had low power with only 24 patients in the
TEP and 28 patients in the TAPP group.
Many of the articles included in the 2005 Cochrane review occurred during the
learning curve for laparoscopic hernia repair [5]. There has been a burst of new
studies published since then. In fact, a 2013 meta-analysis of RCTs comparing TEP
and TAPP [7] found seven total RCTs [6, 8–13] for 516 patients and 538 hernia
defects to analyze. An eighth RCT was published just after the meta-analysis in the
same year [14]. In the 2013 meta-analysis, Antoniou etal. found shorter recovery
time but higher operative morbidity for the TEP group.
The meta-analysis also observed a high rate of morbidity in general for both
laparoscopic procedures (11.9% for TEP, 24.8% for TAPP), which the authors
mostly attributed to two of the seven trials. Pokorny etal. included postoperative use
of analgesics as a morbidity, and when this was removed, the operative morbidity
decreased drastically to a more commonly accepted rate. Dedemadi etal. also found
a high rate of operative morbidity, but this study exclusively looked at repair of
recurrent hernias, which carries higher risks of morbidity [15].
However, only one of the studies strictly compared TEP to TAPP [13], while the
rest compared laparoscopic to open and included a subanalysis of the two
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