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113
9. Femoral Hernia
resection and, although biologic mesh has been used in these situations,
there is not enough data at this time to recommend against primary suture
repair. In fact, small primary femoral hernias (without concomitant
inguinal hernia) in non-obese patients may be repaired with suture.
Polypropylene cylindrical plugs have been associated with a discomforting
foreign-body sensation and higher recurrence and seroma rates ( 20 ).
Incarcerated and strangulated femoral hernias should be approached
from either an inguinal or preperitoneal incision if open, or a TAPP repair
if laparoscopic. The femoral approach may make reduction diffi cult and
it will prevent adequate assessment of the bowel and resection if needed.
Laparoscopic TEP repair in the face of incarceration makes tearing the
peritoneum likely which requires conversion to a TAPP if resection of
the bowel is needed.
A common conundrum occurs if, upon laparoscopy, no hernia (as
evidenced as no peritoneal dimpling) is identifi ed. The peritoneum
should be opened and a repair should be performed as planned.
Recurrences after failing to identify a retroperitoneal hernia are common.
We encourage a meticulous search for an inguinal or femoral lipoma, as
well as for other frequent etiologies of the clinical diagnosis of groin
hernias is encouraged ( 24 ).
At our center, we have repaired over 2000 groin hernias using a
laparoscopic approach. Unless a contraindication exists (obliteration of
the preperitoneal space from surgery or radiation or a risk of general
anesthesia), we routinely employ a laparoscopic approach as this
facilitates evaluation and treatment of all potential groin hernia sites
including the femoral hernia.
References
1. Babar M, Myers E, Matingal J, Hurley ML. The modifi ed Nyhus-Condon femoral
hernia repair. Hernia 2010;14:271–285.
2. Crawford DL, Hiatt JR, Phillips EH. Laparoscopy identifi es unexpected groin hernias.
Am Surg 1998;64(10):976–978.
3. Griffi n KJ, Harris S, Tang TY, Skelton N, Reed JB, Harris AM. Incidence of
contralateral occult inguinal hernia found at the time of laparosocpi trans-abdominal
pre-peritoneal (TAPP) repair. Hernia 2010;14:345–349.
4. Chan G, Chan CK. Longterm results of a prospective study of 225 femoral hernia
repairs: Indications for tissue and mesh repair. J Am Coll Surg 2008;207(3):360–367.
5. Dahlstrand U, Wollert S, Nordin P, Sandblom G, Gunnarsson U. Emergency femoral
hernia repair. A study based on a national register. Ann Surg 2009;249(4):672–676.
114
D.E. Swartz and E.L. Felix
6. Garg P, Ismail M. Laparoscopic total extraperitoneal repair in femoral hernia without
fi xation of the mesh. JSLS 2009;13:597–600.
7. Suppiah A, Gatt M, Barandarian J, Heng MS, Perry EP. Outcomes of emergency and
elective femoral hernia surgery in four district general hospitals: a 4-year study. Hernia
2007;11(6):509–512.
8. Van den Hueval B, Dwars BJ, Klassen DR, Bonjer HJ. Is surgical repair of an
asymptomatic groin hernia appropriate? A review. Hernia 2011 Epub ahead of print.
9. Bendavid R. Femoral hernia (Part III): An “umbrella” for femoral hernia repair. In:
Bendavid, R., ed. Prostheses and Abdominal Wall Hernias . Boca Raton, CRC Press,
1994:413.
10. Lau WY. History of treatment of groin hernia. World J Surg 2002;26(6):748–759.
11. Lichtenstein IL, Shore JM. Simplifi ed repair of femoral and recurrent inguinal hernias
by a “plug” technique. Am J Surg 1974;128(3):439–444.
12. Read RC. British contributions to modern herniology of the groin. Hernia 2005;9(1):
6–11.
13. Moschowitz AV. Femoral hernia; a new operation for radical cure. New York J Med
1907;21:1087.
14. Nyhus LM, Condon RE, Harkins HN. Clinial experiences with preperitoneal hernia
repair for all types of hernia of the groin. Am J Surg 1960;100:233–244.
15. Stoppa R, Petit J, Abourachid H, et al. Procede original de plastie des hernia de l’aine:
L’Interposition sous fi xation d’une prothese en tulle de Dacron par voie mediane sous-
peritoneale. Chirurgie 1973;99(2):119–23.
16. Kugel, RD. The Kugel repair for groin hernias. Surg Clin N Am. 2003;83(5):
1119–1139.
17. Schultz LS, Graber JN, Peritrafi tta J, Hickok DF. Early results with laparoscopic
inguinal herniorrhaphy are promising. Clin Laser Mon 1990;8(7):103–5.
18. McKernan, JB, Laws, HL. Laparoscopic repair of inguinal hernias using a totally
extraperitoneal prosthetic approach. Surg Endosc 1993;7(1):26–28.
19. Franklin ME Jr, Gonzalez JJ, Glass JL. Use of porcine small intestinal submucosa as a
prosthetic device for laparoscopic repair of hernias in contaminated fi elds: 2-year
follow-up. Hernia 2004;8(3):186–189.
20. Chen J, Lv Y, Shen Y, Liu S, Wang M. A prospective comparison of preperitoneal
tension-free open herniorrhaphy with mesh plug herniorrhaphy for the treatment of
femoral hernias. Surgery 2010;148:976–981.
21. Mikkelsen T, Bay-Nielsen M, Kehlet H. Risk of femoral hernia after inguinal
herniorrhaphy. Brit. J. Surg . 2002;89(4):486–488.
22. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO et al. Watchful waiting vs repair of
inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA
2006;295(3):285–292.
23. O’Dwyer, P.J., Norrie, J., Alani, A., et al.: Observation or operation for patients with
an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg 2006;244(2):
167–173.
24. Hollinsky C, Sandberg S. Clinically diagnosed groin hernias without a peritoneal sac
at laparoscopy – what to do? Am J Surg 2010;199(6):730–735.
Part III
Outcomes and Complications
Following Inguinal Hernia Repair
117
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_10,
© Springer Science+Business Media New York 2013
10. Results of Laparoscopic Repair
of Inguinal Hernia
Daniel Marcus
The Evolution of the Laparoscopic Technique
The surgical history of inguinal hernias dates back to ancient Egypt.
From Bassini’s heralding of the modern era to today’s mesh-based open
and laparoscopic repairs, this history parallels closely the evolution in
anatomical understanding and development of the techniques of general
surgery. The evolution of minimally invasive approach to the repair of
inguinal hernias began in the early 1990s as the revolution of
laparoscopic surgery began. The introduction of laparoscopic
cholecystectomy was the fi rst of many procedures in general surgery
tried by surgeons via laparoscopic technique. The laparoscopic
technique began with the IPOM (intraperitoneal placement of mesh).
This technique was fi rst to be published, seemed appealing because the
simple procedure could be adapted by surgeons easily (reference by
early studies). It soon became clear that this technique was fraught with
issues due to high risk of complications and recurrence. Early reports
revealed a recurrence rate of 43% at 41 months compared to 15% to
conventional anterior repair [ 1 ] .
The next technique to be promoted for inguinal hernia repair was the
transabdominal preperitoneal approach or TAPP. This mirrored the
established technique of laparoscopy which was becoming the norm for
many procedures.
The totally extraperitoneal or TEP technique followed the TAPP as
the evolution in inguinal hernia repair continued. This allows the surgeon
to avoid any dissection inside the abdomen and therefore minimize the
risk of injury in the short term and adhesion between the mesh and the
bowel in the long term.
Accounting for 75% of all abdominal wall hernias, and with a lifetime
risk of 27% in men and 3% in women, inguinal hernia repair is one of the
118
D. Marcus
most commonly performed surgeries in the world [ 2 ] . In the United
States, inguinal herniorrhaphy accounts for approximately 800,000 cases
annually.
Most randomized studies comparing laparoscopy to open repair have
con fi rmed the following fi ndings [
3, 4 ] :
Pros:
Reduced postoperative pain •
Earlier return to work •
Cons:
Increased cost •
Lengthier operation •
Steeper learning curve •
Higher recurrence and complication rates early in a •
surgeon’s experience
Although open, mesh-based, tension-free repair remains the criterion
standard, laparoscopic herniorrhaphy, in the hands of adequately trained
surgeons, produces excellent results comparable to those of open repair [ 4 ] .
In a comparison of open repair with laparoscopic (totally extraperitoneal
patch) repair, Eklund et al. found that 5 years postoperatively, 1.9% of
patients who had undergone laparoscopic repair continued to report moderate
or severe pain compared with 3.5% of those in the open repair group [ 5 ] .
De fi nitions
Laparoscopic inguinal herniorrhaphy can refer to any of the following
three techniques:
Totally extraperitoneal (TEP) repair: See the sections below for a
detailed description of this technique.
Transabdominal preperitoneal (TAPP) repair: The abdomen is
accessed, and pneumoperitoneum is achieved using standard laparoscopic
techniques. The preperitoneal space is then exposed transabdominally by
sharply incising and bluntly stripping the peritoneum that overlies the
inguinal anatomy. A mesh is then deployed and fi xed in place as with the
TEP technique and the peritoneum returned to its anatomical position.
Intraperitoneal onlay mesh (IPOM) repair: A dual-layer mesh is placed
over the myopectineal ori fi ce transabdominally and fi xed in place. The
preperitoneal space is not entered, and minimal dissection is carried out.
119
10. Results of Laparoscopic Repair of Inguinal Hernia
TEP and TAPP
The most commonly performed laparoscopic techniques are the TEP
and TAPP repairs [
6, 7 ] . Laparoscopic hernia repair was fi rst described by
Ger in 1990, who placed a simple mesh plug in the defect [ 8 ] . The
technique has undergone a signi fi cant metamorphosis during the last few
years. Currently, there are two types of laparoscopic hernia repair: the
transabdominal preperitoneal (TAPP) repair (as described in this chapter)
and the totally extraperitoneal (TEP) repair. The TEP involves creation of
an extraperitoneal space posterior to the inguinal canal either with a Veress
needle or more commonly a balloon and placement of a mesh in a similar
fashion to the TAPP repair. The TEP may have some advantages over the
TAPP in terms of postoperative pain and reduced potential for intraperitoneal
complications but does require a high level of technical skill associated
with a considerable learning curve. Many surgeons initially learned the
TAPP technique as it was considered easier and was the fi rst technique
introduced after the IPOM. With the introduction of the TEP method with
the preperitoneal balloon dissection, many began to prefer this technique.
The theoretical advantages of the TEP were the fact that the peritoneum is
totally avoided, thereby reducing greatly the risk of adhesions to the bowel
by the mesh. Those who prefer TAPP repairs believe they are technically
easier, provide a better view of the anatomy, and do not require further
equipment beyond that normally available in most departments performing
laparoscopic cholecystectomy. Several studies have demonstrated a clear
advantage of laparoscopic hernia repair over open repair in terms of
reduced postoperative pain and earlier return to work and normal activities.
Despite this, the laparoscopic approach has been slow to gain popularity
among many surgeons. This is due to a number of factors. Firstly, more
advanced technical skills are required compared with a Lichtenstein repair.
Most surgeons who have not had special training, i.e., fellowship or
extensive preceptorship, have dif fi culty making the transition to the
laparoscopic approach. This explains why only an estimated 30% of all
inguinal hernias are performed by either TAPP or TEP. The fi nancial
considerations also play a role certainly. The reimbursement for the
laparoscopic technique is no greater for the most part than a conventional
open technique, both of which are quite low compared to other procedures.
This may contribute to the incentive for a general surgeon to invest the
time and dedication needed to reach competency in this procedure.
Nowadays, the majority of general surgeons do have quite extensive
experience with laparoscopy in cholecystectomy, and this is suf fi cient to
be able to perform a TAPP repair. Recurrence rates are very low with both
120
D. Marcus
the open and laparoscopic mesh repairs with randomized studies showing
no difference between the two. In these studies, the use of large pieces of
mesh seems to help to reduce long-term recurrences. Complications with
experience and technical improvements are now minimal in the
laparoscopic repair, and studies indicate similar complication rates
between open and laparoscopic repairs. Open repairs appear to have a
higher rate of groin hematoma and genital edema. One disadvantage of the
laparoscopic repair is an increase in cost because of the equipment required
[ 1 ] , but with earlier return to work, this cost is outweighed by the bene fi ts
to patient and society. A major advantage of the laparoscopic approach is
the ability to detect and repair a contralateral defect at the same operation
with only a moderate increase in operating time.
As with laparoscopic cholecystectomy, there is a de fi nite learning
curve with the laparoscopic approach to inguinal hernia repair, with the
TEP technique requiring more of a learning curve than TAPP but that
with general laparoscopic experience the learning curve for hernia repair
will become short, thus minimizing the chances of complications seen
during the development of this procedure.
Some earlier studies showed increased recurrence rates with the
laparoscopic technique and questioned the added cost ( 8 VA Study).
However, over the past several years, more studies have shown that when
performed by experienced surgeons with high volume of laparoscopic
procedures, there is a clear advantage. The added cost earlier criticized is
offset by the quicker return to baseline function and the advantage of
exploring and repairing the contralateral side if indicated. Additional
techniques avoiding use of costly deposable products (i.e., balloon
dissection devices) further bring the cost down.
The relatively newer technique of single incision or single port (SILS
and SPA) as well as robotic surgery has introduced the potential for
further reducing the number of port sites. There have been reports that
these techniques may be on par with conventional laparoscopic methods.
The question as to whether these procedures will have signi fi cant
advantages is currently being evaluated in many centers.
References
1. Kingsley D, Vogt DM, Nelson MT, et al. Laparoscopic intraperitoneal onlay inguinal
herniorrhaphy. Am J Surg. 1998;176(6):548–53.
2. Jenkins JT, O’Dwyer PJ. Inguinal hernias. BMJ. 2008;336(7638):269–72.
121
10. Results of Laparoscopic Repair of Inguinal Hernia
3. McCormack K, Scott NW, Go PM, Ross S, Grant AM. Laparoscopic techniques versus
open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003;CD001785
4. Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR. Meta-analysis of
randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J
Surg. 2003;90(12):1479–92.
5. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United
States in 2003. Surg Clin North Am. 2003;83(5):1045–51. v-vi.
6. Eklund A, Montgomery A, Bergkvist L, Rudberg C. Chronic pain 5 years after
randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair. Br J
Surg. 2010;97(4):600–8.
7. Castorina S, Luca T, Privitera G, El-Bernawi H. An evidence-based approach for
laparoscopic inguinal hernia repair: lessons learned from over 1,000 repairs. Clin Anat.
2012 Jan 24. [Epub ahead of print]
8. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons Jr R, Dunlop D, Gibbs J,
Reda D, Henderson W, Veterans Affairs Cooperative Studies Program 456 Investigators.
Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med.
2004;350:1819–27.
123
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_11,
© Springer Science+Business Media New York 2013
11. Outcomes After Transabdominal
Preperitoneal Inguinal Hernia Repair
Nicole Fearing and Kimberly Ponnuru
Hernia surgery remains one of the most common general surgical
procedures in the United States and Europe today. Surgeons perform
approximately 600,000–800,000 inguinal hernia repairs in the United
States yearly [ 1– 3 ] . While most repairs utilize an open technique,
laparoscopic hernia surgery comprises 10–15% of all repairs [ 2, 3 ] .
Several surgeons reported performing the transabdominal preperitoneal
in 1992. The fi rst description of a transabdominal preperitoneal repair
(TAPP) was by Arregui and his colleagues in 1992 [ 4 ] . Laparoscopic
TAPP is often compared to the open inguinal hernia repair and the
laparoscopic totally extraperitoneal repair (TEP). When discussing
methods of hernia repair with a patient, topics such as recurrence, return
to work time, cost, pain, neuralgia, and other complications should be
reviewed.
Complications
Open repair, TAPP, and TEP repair all carry the risk of infection,
groin hematoma, postoperative pain, recurrence, urinary retention,
testicular complaints, and mesh-related complications. In addition,
laparoscopic repairs have risks unique to laparoscopy such as trocar or
Veress needle injuries, port site herniation, and hypercarbia or hypotension
secondary to pneumoperitoneum [ 5 ] .
124
N. Fearing and K. Ponnuru
Bowel Obstruction
TAPP repair can be complicated by bowel obstruction from migration
of the intestine beneath the peritoneal fl ap. This can largely be prevented
by careful tacking or suturing of the peritoneal fl ap over the mesh at the
completion of the procedure. Kapiris et al. reported their results of 3,530
repairs in 3,017 patients with the TAPP repair [
6 ] . In their experience, they
had a total of seven small bowel obstructions due to bowel herniating into
the peritoneum . They changed their technique from reapproximating the
peritoneum with staples over the mesh to suturing it closed with a running
suture. This change in peritoneal closure decreased the incidence of bowel
obstruction from 0.8% with a stapled closure to 0.1% with sutured closure
[ 6 ] . Obstructive symptoms in the immediate postoperative period require a
thorough investigation to exclude the diagnosis of peritoneal herniation.
This may be done by physical exam, ultrasound, or CT scan. If missed,
peritoneal hernia can lead to adherence of small bowel to mesh with erosion
of the mesh or incarceration and eventual strangulation of the bowel. When
caught early, repair may be done laparoscopically with little sequelae.
Urological Complications
Urologic complications following TAPP exist but are rare. Most are
minor and include scrotal seroma or hematoma, testicular pain, and
secondary hydroceles [ 7, 8 ] . A few reports of major urologic complications
have been reported as both short-term and long-term complications.
Bladder injury is a rare but serious complication that can present at the
time of surgery or within a few days of surgery. It has been reported to
occur in less than 1% of patients [ 9 ] . There is no consensus regarding the
routine use of urinary catheters at the time of surgery, although some
surgeons do routinely place them and others do not. At the time of initial
surgery, if a bladder injury is suspected, a urinary catheter may be inserted
(if not already present), and methylene blue saline may be infused into
the bladder to pinpoint the place of injury. Surgical repair of the bladder
and mesh removal are usually required due to concern about mesh
infection in this setting.
Erosion of the mesh into the bladder has been reported years after the
initial TAPP. Mesh removal and surgical repair of the bladder were
required. Mesh removal has been done in a formal open fashion as well
as endoscopically [
7, 10 ] .