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219
19. Laparoscopic Versus Open Repair for the Uncomplicated
a strangulation or a bowel obstruction) were uncommon at a rate of 1.8 per
1,000 patient years, which translates into a cumulative risk of one fi fth of
1% per year. At 2 years, 23% of the watchful waiting patients had crossed
over to receive surgical repair, but that still left the majority that had
avoided an operation. Further analysis of the data in this study showed that
watchful waiting approach was cost effective [ 12 ] and that patients who
ultimately cross over to operation because of symptoms do as well as those
who proceed with immediate repair [ 13 ] . Longer-term results are pending.
O’Dwyer [ 14 ] performed a similar randomized controlled trial but at a
single specialized institution in Scotland and did not report as favorable
results. At 1 year, there was a trend, which suggested that operating on
asymptomatic patients might improve quality of life and reduce potentially
serious morbidity. In a second publication, using Kaplan–Meier estimates,
these investigators predict a conversion rate from observation to operation
of 84% at 7.5 years. They concluded “there seems little point in watchful
waiting because the majority of patients will require an operation in the
foreseeable future.” This study was limited to patients older than 55 years
of age who had to have a visible bulge to qualify for watchful waiting.
Thus, the population was older and had more advanced hernias than in the
former study, there were signi fi cantly smaller number of patients (160),
and revised calculations were needed after the study had been initiated due
to slow accrual to achieve 80% power. (The percentage of asymptomatic
patients who were expected to develop pain was changed from 15% to
20%.) As a result of these trials, many surgeons and patients opt for
watchful waiting approach for minimally symptomatic inguinal hernias.
The recent guidelines published by the European Hernia Society
recommend that watchful waiting is an acceptable option for men with
minimally symptomatic or asymptomatic inguinal hernia [ 15 ] . Of note,
these studies recruited only men with inguinal hernias. This is because the
natural history of a groin hernia is worse in women than in men [ 16 ] , and
hence, all women should be offered repair regardless of symptoms.
What Repair, Laparoscopic or Open?
Anesthesia
Laparoscopic repair of inguinal hernia almost always requires general
anesthesia, while open repair can be easily performed under local or
regional anesthesia. The use of local anesthesia has been shown to result
220
P. Pallati and R.J. Fitzgibbons Jr.
in shorter duration of admission, less postoperative pain, and fewer
micturition dif fi culties [ 17 ] . The patient satisfaction rates are also high.
Despite the powerful argument in favor of local anesthesia for a
conventional inguinal herniorrhaphy, it is underutilized as it is used in
only 6–18% open repairs [ 18 ] . Thus, the importance of this argument for
conventional surgery is greatly diminished.
Early Complications
There is a higher rate of rare but serious intraoperative complications
with the laparoscopic approach. Major vascular and visceral (especially
bladder) injury has been reported and is seen more commonly with the
TAPP procedure (0.65% versus 0–0.17% for TEP and open mesh repair).
Trocar sleeve site hernias and intestinal obstruction due to inadequate
peritoneal closure or adhesions are also theoretically more likely with
the TAPP procedure. Other local complications including hematoma and
wound infection are more often seen with open approach, while seroma
formation is common with laparoscopic approach.
In the Veterans Affairs (VA) cooperative trial discussed above [ 10 ] , the
overall incidence of intraoperative and immediate postoperative
complications was higher in the laparoscopic group including life-threatening
events. However, in a meta-analysis performed by Schmedt et al. [ 19 ] , a
signi fi cantly higher total morbidity was found for the Lichtenstein repair
compared to laparoscopic repair when the VA trial was excluded.
Late Complications
Recurrence
Recurrence of the hernia remains the most import parameter to
measure the ef fi cacy of an inguinal hernia repair. Since 1996, a number
of randomized trials have compared laparoscopic and open mesh repairs
of inguinal hernias (Table 19.1 ). In the VA trial, the recurrence rate was
signi fi cantly higher among patients with unilateral inguinal hernia in the
laparoscopic group than in the open group (10.1% versus 4.0%; OR 2.9;
95% CI, 1.8–4.5). However, the study also has shown that in the hands of
highly experienced surgeons (>250 laparoscopic hernia repairs), the
recurrence rate was comparable between laparoscopic and open repairs
(5.1% versus 4.1%; OR 1.3; 95% CI, 0.6–2.7). Similarly, Langeveld
221
19. Laparoscopic Versus Open Repair for the Uncomplicated
Table 19.1. Comparative trials of laparoscopic and open inguinal hernia repair using mesh.
Author, year
Hernias (n)
LH vs. OH Intervention
Recurrence
rate (%) Salient results
Horeyseck et al. 1996 100 vs. 100 TAPP vs. Lichtenstein 8 vs. 0 Higher recurrence, higher cost
Zieren et al. 1996 86 vs. 105 TAPP vs. PP 2.3 vs. 0 Higher recurrence, higher cost, similar
complications
Sarli et al. 1997 64 vs. 66 TAPP vs. Lichtenstein 0 vs. 0 Similar complications, missed contralat-
eral hernias in OH group
Champault et al.
1997
50 vs. 50 TAPP vs. Stoppa 6 vs. 2 Lower morbidity, higher patient comfort,
higher recurrence rate
Khoury et al. 1998 169 vs. 146 TAPP vs. MP 2.5 vs. 3 Similar recurrence rates, earlier return to
normal activity, fewer nerve
complications
Paganini et al. 1998 52 vs. 56 TAPP vs. Lichtenstein 2 vs. 0 Similar return to normal activity, higher
cost
Aitola et al. 1998 24 vs. 25 TAPP vs. Lichtenstein 13 vs. 8 Similar return to work, higher recurrences
Picehio et al. 1998 53 vs. 52 TAPP vs. Lichtenstein Not
mentioned
Higher pain scores, similar recovery
periods
Kumar et al. 1999 25 vs. 25 TEP vs. Lichtenstein 4 vs. 8 Lower pain score, fewer local
complications
Johansson et al. 1999 613 total TAFP vs. preperitoneal
mesh vs. conventional
2 vs. 5.5 vs. 2 Earlier resumption of normal activity and
return to work, higher cost
MRC group 1994 468 vs. 460 TEP vs. mainly tension
free
1.9 vs. 0 Earlier resumption of normal activity, less
long-term pain, higher recurrence rate
Beets et al. 1999 56 vs. 52 TAPP vs. Stoppa 12.5 vs.1.9 Lesser pain, fewer early complications
Sarli et al. 2000 40 vs. 46 TAPP vs. Lichtenstein 0 vs. 4.3 Lesser pain, earlier return to work
(continued)
222
P. Pallati and R.J. Fitzgibbons Jr.
Table 19.1. (continued)
Author, year
Hernias (n)
LH vs. OH Intervention
Recurrence
rate (%) Salient results
Writiht et al. 2002 145 vs. 151 TEP vs. mostly
Lichtenstein
2 vs. 2 Similar recurrences, similar missed
contralateral hernias
Pikoulis et al. 2002 309 vs. 234 TAPP vs. MP 1.9 vs. 0.4 Higher cost, higher recurrence rate
Mahon et al. 2003 60 vs. 60 (all bilateral
or recurrent)
TAPP vs. Lichtenstein 6.7 vs. 1.7 Shorter operative lime, less pain, earlier
return to work
Andersson et al. 2003 81 vs. 87 TEP vs. Lichtenstein 2.5 vs. 0 Similar complications, earlier return to
work, less pain, higher recurrence rate
Douek et al. 2003 122 vs. 120 TAPP vs. Lichtenstein 1.6 vs. 2.5 Less groin pain, less frequent paresthesias
Bringman et al. 20O3 Total no − 298 TEP vs. MP vs.
Lichtenstein
1.3 vs. 1.3 Shorter sick-leave period, less time to full
recovery
Lal et al. 2003 25 vs. 25 TEP vs. Lichtenstein 0 vs. 0 Earlier return to work, better cosmesis,
similar recurrence rate
Colak et al. 2003 67 vs. 67 TEP vs. Lichtenstein 2.9 vs. 5.9 Short follow-up
Heikkinen et al. 2004 62 vs. 61 TAPP vs. Lichtenstein 8 vs.3.2 Similar recurrence rate, less long-term
groin pain
Neumayer et al. 2004 862 vs. 834 TAPP/TEP vs.
Lichtenstein
10.1 vs. 4 Less pain, higher recurrence rate for
primary hernias
Lau et al. 2006 100 vs. 100 TEP vs. Lichtenstein 0 vs. 0 1-year data only, increased chronic pain
Eklund 2007 73 vs. 74 TAPP vs. Lichtenstein 19 vs. 18 Recurrent hernias, less postoperative pain
and sick leave
Butters et al. 2007 81 vs. 76 vs. 74 TAPP vs. Lichtenstein
vs. Shouldice
1.2 vs. 1.3
vs. 8.1
Open repair associated with nerve injury
223
19. Laparoscopic Versus Open Repair for the Uncomplicated
Author, year
Hernias (n)
LH vs. OH Intervention
Recurrence
rate (%) Salient results
Hallen 2008 73 vs. 81 TEP vs. Lichtenstein 4.3 vs. 5.1 Increased testicular pain in TEP group,
long-term follow-up of old data
Pokorny et al. 2008 Total no − 365 TEP vs. TAPP vs.
Bassini vs. Shouldice
vs. Lichtenstein
5.9 vs. 4.7 vs.
3.4 vs. 4.7
vs. 0.0
Small number of patients
Eklund et al. 2009 665 vs. 705 TEP vs. Lichtenstein 3.5 vs. 1.2 Three surgeons in the TEP group were
responsible for 57% (12/21) of all
recurrences, less chronic pain
Langeveld et al. 2010 336 vs. 324 TEP vs. Lichtenstein 3.8 vs. 3.0 Higher intraoperative complications,
similar pain
LH laparoscopic hernia repair, OH open inguinal hernia repair, TAPP transabdominal preperitoneal hernia repair, PP patch plug repair, MP mesh plug
repair, TEP totally extraperitoneal repair
224
P. Pallati and R.J. Fitzgibbons Jr.
et al. [ 20 ] have shown that experience decreases the incidence of
recurrence with laparoscopic approach.
On further meta-analysis performed by the European Hernia Society
working group on data with a minimum of 4 years follow-up, the
Lichtenstein technique performs slightly but not signi fi cantly better
concerning the recurrence, OR of 1.16 (95% CI, 0.63–2.16).
The literature considering recurrence after TAPP versus TEP is not
elaborate. At the time of a meta-analysis published in 2005, there was
only one randomized controlled study [ 21 ] , and it included a small number
of patients. The meta-analysis [ 22 ] showed that there were no differences
between the two groups, but con fi dence intervals were all very wide, and
hence, it does not rule out clinically important differences.
Chronic Pain
Early literature which discussed the incidence of chronic pain such as
the VA trial [ 10 ] or a meta-analysis performed by the respected European
hernia trialist group [ 23 ] showed little difference between the laparoscopic
and open repair. However, Table 19.2 is a representative collection of
relatively recent studies, which consistently show that LIH performs
better than TFR in this regard. Aasvang and colleagues [ 24 ] studied 464
patients from Denmark and Germany using sophisticated tools designed
to identify risk factors for postoperative pain. They determined that TFR
was a risk factor for chronic pain at 6 months. Based on this literature,
the European Hernia Society guidelines [ 15 ] state, “When only
considering chronic pain, endoscopic surgery is superior to open mesh.”
Most of the literature dealing with chronic groin pain is relatively
short term. However, Eklund et al. [ 25 ] published a randomized controlled
trial comparing TEP LIH with a Lichtenstein TFR, which showed that
the frequency of any degree of chronic pain up to 5 years after operation
was twice as high in the Lichtenstein group as in the TEP group. Moderate
to severe pain occurred in 1.9% patients in the TEP group versus 3.5% in
the Lichtenstein group at 5 years. They conclude, “the present study
demonstrated an advantage of TEP over Lichtenstein hernia repair with
respect to chronic postoperative pain at long-term follow-up.”
Contralateral Hernia
The ability to easily explore the opposite groin at the time of LIH has
resulted in an incidence of contralateral hernia much higher than one
225
19. Laparoscopic Versus Open Repair for the Uncomplicated
Table 19.2. Studies comparing chronic groin pain after open versus laparoscopic inguinal hernia repair.
Author, year Study design Intervention
Incidence of
pain (%) Salient features
Macintyre et al. 2002 Questionnaire study TEP vs. Lichtenstein 22.5 vs. 38.3 Mean follow-up of 21 months
Grant et al. 2004 Prospective
randomized study
TEP vs. Lichtenstein 18.1 vs. 20.1 Questionnaire study of a random-
ized trial
Gunnarson et al. 2006 Retrospective study TEP/TAPP vs.
Lichtenstein
25 vs. 32 Study from Swedish Hernia
registry
Berndsen et al. 2007 Prospective
randomized study
TAPP vs. Shouldice 8.5 vs. 11.4 Non-mesh open technique
Beldi et al. 2008 Retrospective study Laparoscopic vs. open
non-mesh vs. open mesh
16.6 vs. 17.5
vs. 25
Small number of patients
Eklund et al. 2010 Prospective
randomized study
TEP vs. Lichtenstein 1.9 vs. 3.5 Chronic pain diminishes with
long-term follow-up
Kehlet et al. 2010 Prospective
non-randomized
study
TAPP vs. Lichtenstein 14.6 vs. 30.3 Light-weight mesh in laparoscopy
compared to heavy-weight
mesh in open group
Bright 2010 Retrospective study TAPP vs. TEP vs. Open 1.5 vs. 3 vs.
0.7
Attendance to chronic pain clinic.
Open is better than laparoscopic
repair.
TAPP transabdominal preperitoneal hernia repair, TEP totally extraperitoneal repair
226
P. Pallati and R.J. Fitzgibbons Jr.
Table 19.3. Studies reporting incidence of contralateral hernia.
Author, year Intervention
Total number
of patients
Incidence of
contralateral
hernia (%)
Phillips et al. 1998 Diagnostic laparoscopy
followed by TEP
73 50
Evans et al. 2000 TAPP 2,000 22
Ferzli et al. 2000 TEP 552 11.2
Koehler et al. 2002 Diagnostic laparoscopy
followed by TEP
69 13
Singhal et al. 2005 TAPP procedure 377 18.8
Oleynikov et al. 2007 TEP 100 22
TEP totally extraperitoneal hernia repair, TAPP transabdominal preperitoneal hernia
repair
would have predicted in the prelaparoscopic era. Table 19.3 is a listing
of LIH publications where the contralateral hernia incidence was
recorded. One can appreciate a rate between 11% and 50%. These
incidentally found hernias can easily be repaired through the same
access ports as the index hernia, and the morbidity has been shown to be
similar in both unilateral and bilateral laparoscopic repairs [ 26 ] . Not
surprisingly, LIH enthusiasts have used this fact as an argument to
support LIH. However, there are two problems with routine repair of a
contralateral hernia. The fi rst is that a consistent de fi nition of an
incidental hernia does not exist, and therefore, what one surgeon calls a
normal variant, another might call a hernia. The second problem revolves
around the issue discussed above, chronic groin pain. Since the vast
majority of these patients are asymptomatic, a strong argument can be
made for doing nothing and take a “watchful waiting” approach. The
rationale for this is to avoid a chronic postherniorrhaphy groin pain
syndrome in a patient who was previously asymptomatic. For these
reasons, debate continues whether there is a role for treatment on the
contralateral side, if the patient is asymptomatic. Surgeons who favor
the TEP approach using a balloon dissector to create the preperitoneal
space tend to have the lowest threshold for contralateral repair because
invariably the contralateral preperitoneal space is at least partially
developed which makes subsequent TEP repair more dif fi cult. In
addition, this partial dissection is thought to increase the occurrence of
a contralateral hernia.
227
19. Laparoscopic Versus Open Repair for the Uncomplicated
Cost-Effectiveness
From a hospital standpoint, the laparoscopic approach is associated
with higher costs compared to the open approach. However, from a
socioeconomic perspective, laparoscopic approach is more cost effective.
McCormack et al. [
27 ] reviewed the cost-effectiveness in 2005 and at
that time showed that when productivity costs and quality of life are
included in the analyses, laparoscopic approach was advantageous.
However, this study based primarily on randomized trials performed in
the late 1990s, and at that time, the operative times were longer for the
laparoscopic approach compared to open. With increasing expertise, the
operative times are equal if not better, and hence, the cost analysis would
probably favor laparoscopic approach. The problem with this analysis is
that the funding for the direct medical costs and socioeconomic costs
does not come from the same “pot.” Although there have been studies
showing equivalent fi nancial expenditure when a concerted effort is
made to minimize items such as disposables for LIH, these tend to be
fl awed because a concerted effort to control the TFR costs is not included.
Just as any gambler knows that in the end, the house is always going to
win based on basic mathematics; it is impossible to take an operation
which can be performed even without an anesthesiologist which only
requires a few instruments, some suture, and a relatively cheap prosthesis
(TFR) and try to argue cost equivalence for an operation which must be
performed under general anesthesia and has expensive high-tech
equipment needs which must be amortized (LIH). Depending upon the
fi nal form of health care reform, which is now inevitable, this could
represent a severe threat to LIH.
Future Pelvic Surgery
An advantage of the TFR procedure is that it does not enter the
preperitoneal space and, therefore, does not affect future operations such
as prostatectomy, which might need to be performed later in life. The
laparoscopic approach, on the other hand, enters the retropubic
preperitoneal space and, with placement of mesh, results in scarring.
Although recent literature suggests that prostatectomy is technically
possible, it is more dif fi cult [ 28 ] . The general consensus at present is to
228
P. Pallati and R.J. Fitzgibbons Jr.
avoid LIH in patients with a strong family history of prostate cancer and
to perform prostate cancer screening in elderly male patients undergoing
laparoscopic inguinal hernia repair.
Recommendations
Watchful Waiting
Adult male with minimal or asymptomatic unilateral inguinal hernia
Open Repair
Large scrotal hernia
Patient who cannot tolerate general anesthesia
Recurrent hernia when original was performed in the preperitoneal
space
↑ risk for prostate cancer
Laparoscopic Repair
Recurrent hernia when original was performed in the conventional
anterior space
Bilateral hernias
Women with groin hernia
Sports hernia
Laparoscopic or Open Repair
Choice for the uncomplicated unilateral hernias should depend on the
surgeon’s expertise.
References
1. DeFrances CJ, Cullen KA, Kozak LJ. National hospital discharge survey: 2005 annual
summary with detailed diagnosis and procedure data. Vital Health Stat.
2007;13(165):1–209.
2. Lyons AS, Pertrucelli II RJ. Medicine: an illustrated history. New York: Harry N.
Abrams Publishers; 1987.