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18. Fixation Versus No Fixation in Laparoscopic TEP and TAPP
should be secured with a stapler. Based on this experiment, Lau et al. [ 30 ]
did selective non fi xation of hernias for the size smaller than 4 cm and
recommended fi xation of mesh for hernias more than 4 cm. The original
open GPRVS repair by Stoppa was designed for the complicated or
recurrent hernia using a very large mesh. In theory, even a defect greater
than 4 cm could be repaired with this approach without fi xation but with
a greater sized mesh. One study found [ 25 ] decreased incidence of
postoperative urinary retention in non fi xation group. Cost containment is
also a consideration during stapling the mesh in laparoscopic hernia
repair. The elimination of the disposable stapling device, either an
endostapler or a helical tacker, can reduce the operative cost by $150–
$300. The helical tacker costs about $293 at our hospital. The markup by
the hospital is likely three times or greater. Persistent groin pain has also
encouraged the use of alternative methods of fi xation that avoid the use of
tacks including fi brin glues, acrylate adhesives, self-gripping mesh, and
absorbable sutures.
Fibrin glue has been proposed as an alternative, atraumatic method for
mesh fi xation based on its effective adhesive and wound- healing properties.
It is a biodegradable preparation combining human plasma-derived
fi brinogen and thrombin. Chevrel and Rath [ 31 ] fi rst proposed fi brin sealant
as an alternate means of mesh fi xation in hernia repair, with the aim of
reducing the rate of hernia recurrence. Katkhouda et al. [ 32 ] have since
employed a pig model using a TEP technique to evaluate the tensile strength
of mesh fi xation 12 days after the use of fi brin sealant, demonstrating equal
strength to staples. In a randomized trial between fi brin glue versus staples in
TAPP repair, Lovisetto et al. [ 33 ] found lower incidence of postoperative
neuralgia. The results of these studies have encouraged surgeons to use fi brin
sealant as an alternative to mechanical mesh fi xation. With the results of
non fi xation being the equivalent to fi xation, fi brin glue seems redundant and
an added expense.
Self-Gripping Mesh Without Additional Fixation
in TAPP and TEP
Recently a new material became available that may preclude the need
for additional fi xation as the mesh itself is self-gripping to muscle and
adipose tissue. Made of a mono fi lament polyester weave with polylactic
acid microhooks on one surface, and shown to be bene fi cial in open
Lichtenstein hernia repairs, this material may have applications in TAPP
210
V.K. Mathavan and M.E. Arregui
and TEP repair. As reported at the American Hernia Society meeting in
2012 held in New York City, Jacob et al. presented early data from a
prospective study. Self-gripping mesh was implanted in 64 hernias repaired
by TEP technique. Follow-up with Carolinas Comfort Scale™ showed that
only 7.7% of the patients were considered symptomatic at the fi rst 2-week
postoperative visit, and 0 patients were symptomatic at the second visit held
between 3 and 6 months after surgery. Patients took an average of fi ve
tablets of narcotic and returned to full unrestricted activity within 5 days.
The mean direct defect size was 2.5 cm, and no additional fi xation was used
in any case. To date, there are no reported recurrences or chronic pain.
Conclusion
The decision to fi x the mesh in laparoscopic hernia repair depends
upon the size of the hernia and the size of mesh used. For small hernia,
the mesh can be safely placed without fi xation. But for large hernias, the
fi xation may be required to prevent recurrence, though there is risk of
nerve entrapment and cost considerations.
References
1. Ger R, Monroe K, Duvivier R, et al. Management of indirect inguinal hernias by
laparoscopic closure of the neck of the sac. Am J Surg. 1990;159:370–3.
2. Arregui ME, Davis CJ, Yucel O. Laparoscopic mesh repair of inguinal hernia using a
preperitoneal approach: a preliminary report. Surg Laparosc Endosc. 1992;2:53–8.
3. McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally
extraperitoneal prosthetic approach. Surg Endosc. 1993;7:26–8.
4. McCormack K, Scott N, Go P, et al. Laparoscopic techniques versus open techniques
for inguinal hernia repair. Cochrane Database Syst Rev. 2003;(1):CD001785.
5. Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent inguinal hernia: randomized
multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc.
2007;21:634–40.
6. Feliu X, Jaurrieta E, Vinas X, et al. Recurrent inguinal hernia: a ten-year review.
J Laparoendosc Adv Surg Tech A. 2004;14:362–7.
7. Kouhia ST, Huttunen R, Silvasti SO, et al. Lichtenstein hernioplasty versus totally
extraperitoneal laparoscopic hernioplasty in treatment of recurrent inguinal hernia-a
prospective randomized trial. Ann Surg. 2009;249:384–7.
211
18. Fixation Versus No Fixation in Laparoscopic TEP and TAPP
8. Itani KM, Fitzgibbons Jr R, Awad SS, et al. Management of recurrent inguinal hernias.
J Am Coll Surg. 2009;209(5):653–8.
9. Mahon D, Decadt M, Rhodes M. Prospective randomized trial of laparoscopic
(transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent
inguinal hernia. Surg Endosc. 2003;17:1386–90.
10. Wauschkuhn C, Schwarz J, Boekeler U, et al. Laparoscopic inguinal hernia repair:
gold standard in bilateral hernia repair? Results of more than 2800 patients in
comparison to the literature. Surg Endosc. 2010;24(12):3026–30.
11. Feliu X, Claveria R, Besora P. Bilateral inguinal hernia repair: laparoscopic or open
approach? Hernia. 2011;15(1):15–8.
12. Takata MC, Duh QY. Laparoscopic inguinal hernia repair. Surg Clin North Am.
2008;88:157–78.
13. Felix EL, Swanstrom, L, Eubanks, S. Laparoscopic inguinal hernia repair. In: Soper
NJ, editor. Mastery of endoscopic and laparoscopic surgery. 3rd ed. Philadelphia, PA:
Lippincott Williams and Wilkins. 2008; 523–37.
14. Spitz JD, Arregui ME. Sutureless laparoscopic extraperitoneal inguinal herniorrhaphy
using reuseable instruments: two hundred three repairs without recurrence. Surg
Laparosc Endosc Percutan Tech. 2000;10:24–9.
15. Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron in the repair of hernias
of the groin. Surg Clin North Am. 1984;64:269–85.
16. Lowham AS, Filipi CJ, Fitzgibbons RJ, et al. Mechanisms of hernia recurrence after
preperitoneal mesh repair. Ann Surg. 1997;225:4211–431.
17. Fitzgibbons RJ, Camps J, Cornet DA, et al. Laparoscopic inguinal herniorrhaphy:
results of a multicenter trial. Ann Surg. 1995;221:3–13.
18. Felix E, Scott S, Crafton B, et al. Causes of recurrence after laparoscopic hernioplasty.
Surg Endosc. 1998;12:226–31.
19. Phillips EH, Rosenthal R, Fallas M, et al. Reasons for early recurrence following
laparoscopic hernioplasty. Surg Endosc. 1995;9:140–5.
20. Kraus MA. Nerve injury during laparoscopic inguinal hernia repair. Surg Laparosc
Endosc. 1993;3:342–5.
21. Kraus MA. Laparoscopic identi fi cation of preperitoneal nerve anatomy in the inguinal
area. Surg Endosc. 1994;8:377–80.
22. Ferzli GS, Frezza EE, Pecararo Jr AM, Ahern KD. Prospective randomized study of
stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair.
J Am Coll Surg. 1999;188(5):461–5.
23. Taylor C, Layani L, Liew V, et al. Laparoscopic inguinal hernia repair without mesh
fi xation, early results of a large randomized clinical trial. Surg Endosc.
2008;22:757–62.
24. Moreno-Egea A, Torralba Martinez JA, Morales Cuenca G, Aguayo Albasini JL.
Randomized clinical trial of fi xation vs non fi xation of mesh in total extraperitoneal
inguinal hernioplasty. Arch Surg. 2004;139(12):1376–9.
25. Koch CA, Greenlee SM, Larson DR, Harrington JR, Farley DR. Randomized
prospective study of totally extraperitoneal inguinal hernia repair: fi xation versus no
fi xation of mesh. JSLS. 2006;10(4):457–60.
212
V.K. Mathavan and M.E. Arregui
26. Messaris E, Nicastri G, Dudrick S. Total extraperitoneal laparoscopic inguinal hernia
repair without mesh fi xation. Prospective study with 1-year follow-up results. Arch
Surg. 2010;145(4):334–8.
27. Khajanchee YS, Urbach DR, Swanstrom LL, Hansen PD. Outcomes of laparoscopic
herniorrhaphy without fi xation of mesh to the abdominal wall. Surg Endosc.
2001;15:1102–7.
28. Smith AI, Rayston MS, Sedman PC. Stapled and nonstapled laparoscopic
transabdominal preperitoneal (TAPP) inguinal hernia repair. A prospective randomized
trial. Surg Endosc. 1999;13:804–6.
29. Hollinsky C, Hollinsky KH. Static calculations for mesh fi xation by intraabdo-
minal pressure in laparoscopic extraperitoneal herniorrhaphy. Surg Laparosc Endosc
Percutan Tech. 1999;9(2):106–9.
30. Lau H, Patil NG. Selective non-stapling of mesh during unilateral endoscopic total
extraperitoneal inguinal hernioplasty: a case control study. Arch Surg. 2003;138(12):
1352–5.
31. Chevral JP, Rath AM. The use of fi brin glues in the surgical treatment of incisional
hernias. Hernia. 1997;1:9–14.
32. Katkhouda N, Mavor E, Friedlander MH, et al. Use of fi brin sealant for prosthetic
mesh fi xation in laparoscopic extraperitoneal inguinal hernia repair. Ann Surg.
2001;233:18–25.
33. Lovisetto F, Zonta S, Rota E, et al. Use of human fi brin glue (Tissucol) versus staples
for mesh fi xation in laparoscopic Transabdominal preperitoneal hernioplasty. Ann Surg.
2007;245:222–31.
213
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_19,
© Springer Science+Business Media New York 2013
19. Laparoscopic Versus Open Repair
for the Uncomplicated Unilateral
Inguinal Hernia
Pradeep Pallati and Robert J. Fitzgibbons Jr.
Inguinal hernias are common; 27% of men and 3% of women will
develop one in their lifetime. In the United States, according to the
National Hospital Discharge Survey, approximately 720,000 inguinal
hernia repairs were performed in the year 2005 [ 1 ] . Descriptions of
Inguinal hernia repairs have appeared in medical writings as far back as
1500 B.C. [ 2 ] . However, the modern era of inguinal herniorrhaphy is
generally felt to have begun in the late 1800s, thanks to the revolutionary
procedure developed by Bassini. His prototype tissue repair was based
on sound anatomical principles and incorporated the developing
disciplines of anesthesia and antisepsis. The steps he recommended to
prepare the groin for the eventual approximation of his famous “triple
layer” (transversalis fascia, transversus abdominis muscle, and internal
oblique muscle) to the inguinal ligament are still used in almost all
conventional open repairs, both tissue- and tension-free. Although this
operation was associated with results unheard of in Bassini’s time,
population-based studies in the twentieth century consistently revealed a
recurrence rate in the 10–15% range when performed in general practice.
The late 1980s and early 1990s saw two parallel developments, which
would profoundly affect the way inguinal hernia surgery was performed.
The fi rst was the widespread acceptance of the routine use of prosthetic
material for all adult inguinal hernias, complicated or uncomplicated.
The second was the development of laparoscopic inguinal herniorrhaphy,
which quickly followed the laparoscopic revolution spawned by the need
to retrain surgeons in the laparoscopic method, so they could continue to
perform cholecystectomy. Now, most surgeons agree that the laparoscopic
method is the procedure of choice for recurrent hernias after a failed
214
P. Pallati and R.J. Fitzgibbons Jr.
open procedure because the repair can be performed in an undissected
space and for bilateral inguinal hernias as both hernias can be repaired
through the same minimal access sites.
A more contentious issue is the application of laparoscopy to the
uncomplicated unilateral inguinal hernia. It is now clear that in
experienced hands, either operation can be associated with low recurrence
rates (i.e., <2%). Because of this fact, recurrence rates as an outcome
metric may be less signi fi cant than some others. So, a discussion
comparing laparoscopic inguinal herniorrhaphy (LIH) with a conventional
open tension-free approach (TFR), the subject of this chapter, has to be
based on other factors such as short- and long-term pain, risk/bene fi t
ratio as it relates to complications, cost, and return to normal activities.
The purpose of this chapter is to explore these other factors to allow the
reader to make state of the art decisions for his or her patient.
Laparoscopic Inguinal Hernia Repair
Ger described the fi rst LIH repair in 1982 [ 3 ] . He used a clip-applying
device to close the internal ring in beagle dogs with congenital indirect
inguinal hernias. His approach did not include reconstruction of the inguinal
fl oor, so would have only been applicable to Nyhus type 1 inguinal hernias.
Technical problems with the clip applier could never be solved, and thus it
was never used in humans on a large-scale basis. Schulz and colleagues tried
to capitalize on Ger’s idea by packing hernia defects with bulky mesh
material. In the end, this approach failed because it did not address the need
to reinforce the entire myopectineal ori fi ce to minimize the chance of
recurrence. But this did lead to the development of the intraperitoneal onlay
mesh repair (IPOM), which will be described brie fl y below.
The most commonly performed laparoscopic repairs today do not
attempt to solve the problem intra-abdominally. Rather, they are
performed in the preperitoneal space in a manner similar to conventional
open preperitoneal inguinal hernia repairs. The principal is to expose all
critical anatomical elements in the preperitoneal space and then to use
prosthetic material to cover the entire myopectineal ori fi ce. The
preperitoneal space can be accessed laparoscopically in two ways:
1. One can perform a laparoscopy, incise the peritoneum from the
abdominal cavity, dissect the preperitoneal space, and then
cover the entire dissected area, the myopectineal ori fi ce, with a
215
19. Laparoscopic Versus Open Repair for the Uncomplicated
widely overlapping prosthesis. This is known as the
transabdominal preperitoneal repair (TAPP) repair.
2. The preperitoneal space can also be entered by dissecting in the
space between the posterior rectus sheath and the rectus muscle to
enter the preperitoneal space without ever purposely breaching the
peritoneal cavity. Once the space is entered, the operation proceeds
in an identical fashion as the TAPP. This is known as the totally
extraperitoneal repair (TEP).
The intraperitoneal onlay mesh repair (IPOM) is the only truly
minimally invasive laparoscopic hernia repair because a radical dissection
of the preperitoneal space is avoided. The principle is that by placing a
large overlapping prosthesis as in the TAPP and TEP one layer deeper,
that is, directly on the peritoneum, a dissection of the preperitoneal space
can be avoided. The IPOM however never became popular because of the
reluctance of surgeons to place prosthetic material in the abdominal
cavity in contact with intra-abdominal viscera. However, with the IPOM
technique now being used routinely for ventral hernias and because of the
development of better prosthetic materials, interest in the technique has
been renewed especially in TAPP or TEP operations when it is determined
that adequate peritoneal coverage of prosthesis is not possible.
Detailed descriptions of these procedures are provided elsewhere in this
manual. What follows though is an abbreviated discussion of the technical
aspects of the two commonly performed laparoscopic herniorrhaphies as
well as the conventional open inguinal herniorrhaphies in order to better
place our comparison of the two approaches into perspective.
Transabdominal Preperitoneal (TAPP) Repair
After obtaining peritoneal access at the umbilicus, diagnostic
laparoscopy is performed to rule out any unrelated pathology, and both
myopectineal ori fi ces are inspected. Two additional trocar sleeves are
placed on either side of the umbilicus. The peritoneum is incised
transversely to a point medial to the anterior superior iliac spine, staying
approximately 2 cm above the internal inguinal ring on the side of the
hernia defect. A combination of blunt and sharp dissection is performed
in the preperitoneal space to expose the critical anatomical landmarks
with the judicious use of electrocautery. Both pubic tubercles, the inferior
epigastric vessels, Cooper’s ligament, and the iliopubic tract are
identi fi ed. The spermatic cord structures are mobilized and the peritoneal
216
P. Pallati and R.J. Fitzgibbons Jr.
fl ap is dissected well proximal to the bifurcation of the vas deferens and
the internal spermatic vessels. A direct hernia sac easily reduces during
the preperitoneal dissection. A small indirect hernia sac can be dissected
away from the cord structures and reduced. A large prosthesis (at least
15 × 10 cm) is placed to generously cover the entire myopectineal ori fi ce,
including the site of potential weakness for a femoral hernia. Slitting of
the mesh laterally to create a new deep ring is optional. If mesh fi xation
is chosen, it is begun at the contralateral pubic tubercle medially
extending onto the anterior abdominal wall at least 4 cm superior to the
hernia defect, to the anterior superior iliac spine laterally, and to the
tissue just above Cooper’s ligament inferiorly. The most common
prosthetic mesh devices are made from polypropylene or polyester,
materials known to erode into intra-abdominal viscera on occasion.
Therefore, meticulous peritoneal coverage of the prosthesis is essential.
The goal is isolation of the prosthesis from the viscera.
Totally Extraperitoneal (TEP) Repair
A three-trocar approach for the TEP repair is used. An infraumbilical
incision is performed and either the ipsilateral or contralateral anterior
rectus sheath is entered vertically, depending upon the preference of the
surgeon. The posterior sheath is visualized after retraction of the rectus
muscle, and blunt dissection develops the space between the rectus
muscle and the posterior rectus sheath, to allow placement of a trocar
sleeve to begin gas insuf fl ation. Additional trocar sleeves are then placed
into this space, either in the midline or laterally. A popular adjunct for
creating the preperitoneal space is to use a dissecting balloon. Once the
preperitoneal space has been completely developed, the operation
proceeds in a fashion identical to the TAPP repair. Unlike the TAPP
repair, closure of a peritoneal fl ap is not necessary.
Open Inguinal Hernia Repair
Conventional open tissue repairs were the mainstay for inguinal hernias
for most of the twentieth century. Indeed, there have been at least 70 different
named tissue repairs described in the literature since the time of Bassini [
4 ] .
However, in the late 1990s, Lichtenstein and colleagues [
5 ] revolutionized
the approach to inguinal hernia repair by popularizing the routine use of
217
19. Laparoscopic Versus Open Repair for the Uncomplicated
prosthetic material to bridge the hernia defect rather than approximate tissue
structures that were not normally in apposition as is performed in the tissue
repairs. Many techniques for placement of a prosthesis are described in the
literature, which are grouped under the heading of tension-free repairs or
TFR. Numerous randomized controlled clinical trials as well as systematic
reviews of the same have unequivocally shown that the TFR procedures are
superior to the tissue repairs for most parameters analyzed. The only
exception might be the Shouldice tissue repair but only when performed in
a specialty center such as the Shouldice clinic. Therefore, for the purposes
of our comparison, only the TFR approach will be considered.
The procedure as described by Lichtenstein is considered the gold
standard TFR. In this technique, the groin is initially prepared by dividing
the external oblique aponeurosis through the external inguinal ring
followed by mobilization of the cord structures from the inguinal fl oor.
Next, the indirect or direct hernia sac and its contents are reduced into
the preperitoneal space after being dissected away from surrounding
structures. Instead of approximating anatomical structures as in tissue
repairs, a large space is created beneath the aponeurosis of the external
oblique from a point at least 2 cm medial to the pubic tubercle to the
anterior superior iliac spine laterally which allows the placement of a
large fl at mesh prosthesis widely overlapping the areas where direct and
indirect hernias occur. The mesh is sutured to the anterior rectus sheath
2 cm medial to the pubic tubercle, and this suture is then continued
laterally in a running fashion, securing the caudal edge of the prosthesis
to either side of the pubic tubercle and the inguinal ligament to the level
of the internal ring. The mesh is then slit to accommodate the cord
structures and the tails thus created are passed beneath the external
oblique to the anterior superior iliac spine with the superior tail
overlapping the inferior. A so-called shutter valve stitch approximates
the inferior surface of the superior tail to the inferior surface of the
inferior tail and the inguinal ligament. The mesh is then trimmed in situ
and fi xed to the rectus sheath medially and the internal oblique muscle
cranially with a few interrupted sutures. The external oblique aponeurosis
is again closed over the cord structures and the skin is approximated.
Multiple other mesh-based TFR techniques have now been described in
the literature, most notable of which is the plug and patch mesh hernioplasty
[ 6 ] , which remains a popular alternative to the classic Lichtenstein. The
preperitoneal space can also be accessed using an open approach as
originally described by Stoppa [ 7 ] but now adapted to a more minimally
invasive open technique such as the Kugel [ 8 ] . The Prolene Hernia System
[ 9 ] exploits both the conventional anterior space and the preperitoneal by
218
P. Pallati and R.J. Fitzgibbons Jr.
using a bilayer prosthesis consisting of two fl at pieces of mesh connected
by a polypropylene cylinder. For the purpose of the comparison in this
chapter, all of these mesh-based procedures will be considered equivalent
when performed by a surgeon experienced in a particular operation.
LIH Versus TFR
The Veterans Affairs Cooperative Studies Program 456:
“Open Mesh Versus Laparoscopic Mesh Repair
of Inguinal Hernia” [ 10 ]
This landmark study was published in 2004 in the New England
Journal of Medicine. This was a well-funded study, which was carefully
developed with clear-cut methods. The study surgeons were experienced
with both techniques but for the most part did not have a specialty interest
in inguinal hernia repair. This was by design because the goal of the study
was to compare LIH to TFR in a setting of general practice rather than a
specialty hernia center. The primary outcome was recurrence at 2 years.
The results were unfavorable for LIH not only in terms of recurrence but
also in many other parameters studied when compared to other randomized
controlled trials especially those performed in laparoscopic centers of
excellence. It has been criticized by LIH proponents that the surgeons
were less skilled. The study certainly cannot be completely discounted
though and may indeed be more re fl ective of how these procedures are
performed in general practice. Because of the large number of patients
involved (2,164), the study can dominate meta-analysis, and this will be
pointed out as we contrast and compare TFR to LIH.
Repair or No Repair?
The initial question to be answered is whether an inguinal hernia needs
to be repaired at all? For a patient presenting with signi fi cant symptoms,
the answer is obviously yes. For patient presenting with minimal or no
symptoms, the answer is not clear. A multicenter, prospective, randomized
controlled trial of watchful waiting versus elective repair published in
JAMA in 2006 [ 11 ] has shown that “a strategy of watchful waiting is a
safe and acceptable option for men with asymptomatic or minimally
symptomatic inguinal hernias.” In this study, hernia accidents (de fi ned as