Laparoscopic Repair of Inguinal Hernia – Is it really needed

The history of hernia, one of the most beautiful chapters in the triumphs of anatomy & surgery, is replete with ideas & realities, myths & facts, transmutations & shadows

The history of hernia in toto is as old as human race After centuries of much success & much failure, we note that every period opened avenues for a better understanding (Raff J. Hernia healers, Ann Med History 1932;4:377)

Ancient times Doctors in Iraq (Area between Euphrates & Tigris rivers) new about herniotomy around 4000 BC Ancient Hindu surgeons treated hernia by severing the sac by cautery Heliodorus was first to perform the hernia surgery scientifically, separated sac from cord Celsus wrote about hernias in his 7th book out of his 8 books De Medicina

Middle ages Orbacius performed herniotomies in the 4th century Paul of Aegina described words enterocele, epiplocele & hydroenteroepiplocele (7th century) William Salicet in 13th century double ligation & division of sac – used knife not cautery & said All is owed to Nature – the doctor is merely her servant also recommended that testis should not be removed “as some stupid & ignorant doctors do”

The Renaissance In 16th century Casper Stromayr & Lindon produce colored illustration to demonstrate operation for cure of hernia. Ambroise Pare advocated the use of truss Lorenz Heister differentiated direct from indirect hernia (1683-1758). He stressed the need for a “surgeon to have complete or at least very good knowledge in anatomy & in medicine so that he has enough judgement & understanding to study the causes & to draw his conclusions”

Hernia trusses

Eighteenth century Better information of anatomy Antonio Scarpa (1752-1832) Albert von Haller (1708-1777) Congenital hernia Percival Pott anatomy of congenital hernia Pieter Camper (1722-89)- Camper’s fascia John Hunter (1728-93) – presence of process vaginalis & gubernaculum testis Franz Hesselbach (1759-1816) Hesselbach’s triangle

Sir Astley Cooper (1768-1841) “No disease of the human body belonging to the province of the surgeon, requires in its treatment a greater combination of accurate anatomical knowledge, with surgical skill, than hernia in its all varieties” He described Cooper’s ligament, cremasteric fascia & fascia transversalis

Nineteenth century Space of Retzius 1858 Space of Bogros – 1823 Georg Lotheissen used cooper’s ligament for repair

Edoardo Bassini (1844-1924) Father of modern herniorrhaphy Ligated & resected the sac First to present to world this technique major contributions was that he performed adequate audit and follow-up of patients All modern modifications of hernia repair spring from the original Bassini repair

Twentieth century Several innovations Marcy Cheatle - First to describe pre peritoneal approach Prosthesis Nyhus

E. Shouldice (1891-1965) Repaired with overlapping layers with continuous sutures Recurrence rate less than 1%

Lichtenstein Repair Tension free repair Use of prosthetic graft

After Bassini’s repair 81 Inguinal 79 femoral operative techniques described A decade later we must humbly remember that despite the latest successes in repair we are in shadows awaiting Theseus.

Myopectineal orifice of Fruchaud

Inguinal hernia repair is one of the most common operations performed by general surgeons, with approximately 750,000 operations done per year in the United States by surgeons who incorporate it as a part of their varied practices. Conventional open repairs without prosthetics are most often successful for small hernias. However, they are plagued in general by a high recurrence rates except in specialized centres

Why so many modifications Recurrence Chronic pain

Laparoscopic repair Ger in 1990 Fitzgibbons IPOM Phillips - extra peritoneal repair by exposing the myopectineal orifice of Fruchauds & placing the polypropylene mesh between peritoneum & the abd wall Arregui 1992 TAPP McKernan 1993 TEP

Lap repair of Hernia Lap technology has been applied to the treatment of hernia. Repair is performed with placement of synthetic mesh into the pre peritoneal space. Many studies devoted to comparing open tension free repair Vs lap repair. Improved the recurrence rate & reduced the chances of persistent pain.

Acceptance of this procedure has been slow Performed by surgeons who are specifically trained Long learning curve

Specific indication Recurrence from prior open inguinal hernia surgery Bilateral inguinal hernia repair When diagnosis is uncertain specially in obese pts Pts who are eager to return to normal physical activity early

Contraindications Unfit for GA Strangulated hernia Incarceration relative contra indication Severe ascitis

Advantages Post operative pain is less Chronic persistent pain less Early return to work Recurrence TAPP .7% TEP .4% Shorter convalescence

Comparison of complication rates between laparoscopic (transabdominal preperitoneal and totally extra peritoneal) and open mesh repair) Investigator Laparoscopic Open TAPP versus open mesh Payne, et al [18] 6 (12%) 9 (18%) Filipi, et al [19] 3 (13%) 3 (10%) Heikkinen, et al [20] 4 (20%) 16 (89%) Aitola, et al [21] 5 (21%) 2 (8%) Heikkinen, et al [22] 5 (28%) 8 (40%) Paganini, et al [23] 14 (27%) 15 (27%) Picchio, et al [25] 14 (26%) 13 (25%) Douek, et al [26] 13 (11%) 52 (43%) Anadol, et al [27]

TEP versus open mesh Investigator Laparoscopic Open Wright, et al [28] 15 (25%) 50 (83%) Champault, et al [29] 2 (4%) 11 (30%) Khoury, et al [31] 20 (13%) 33 (23%) Andersson, et al [32] 7 (9%) 4 (5%) Bringman, et al [33] 9 (10%) 21 (20%) Colak, et al [34] 10 (13%) 11 (16%) Lal, et al [35] 6 (24%) 3 (12%) Eklund, et al [36] 83 (14%) 101 (16%)

Comparison of postoperative pain between laparoscopic (transabdominal preperitoneal and totally extraperitoneal) and open mesh repair Investigator In favor of laparoscopy or open TAPP versus open mesh Filipi, et al [19] Laparoscopy Heikkinen, et al [20] Aitola, et al [21] Heikkinen, et al [22] No difference Paganini, et al [23] Wellwood, et al [24] Picchio, et al [25] Anadol, et al [27]

TEP versus open mesh Investigator In favor of laparoscopy or open Wright, et al [28] Laparoscopy Champault, et al [29] Heikkinen, et al [30] Khoury, et al [31] Andersson, et al [32] Bringman, et al [33] Colak, et al [34] Lal, et al [35] Eklund, et al [36]

Comparison of time to return to work between laparoscopic (transabdominal preperitoneal and totally extraperitoneal) and open mesh repair Time to return to work (days) Investigator Laparoscopic Open Heikkinen, et al [20] 14 19 Aitola, et al [21] 7 5 Heikkinen, et al [22] 21 Paganini, et al [23] 15 Wellwood, et al [24] 26 Picchio, et al [25] 46 43

TEP versus open mesh Investigator Laparoscopic Open Champault, et al [29] 17 35 Heikkinen, et al [30] 12 Khoury, et al [31] 8 15 Andersson, et al [32] 11 Bringman, et al [33] 5 7 Colak, et al [34] Lal, et al [35] 13 19 Eklund, et al [36]

Comparison of recurrence rates between laparoscopic (transabdominal preperitoneal and totally extraperitoneal) and open mesh repair Investigator Laparoscopic Open TAPP versus open mesh Payne, et al [18] Filipi, et al [19] 2 (7%) Heikkinen, et al [20] Aitola, et al [21] 13% 8% Heikkinen, et al [22] Paganini, et al [23] 2 (3.8%) Wellwood, et al [24] Douek, et al [26] 2 (2%) 3 (3%) Anadol, et al [27]

TEP versus open mesh Investigator Laparoscopic Open Champault, et al [29] 3 (6%) 1 (2%) Heikkinen [30] Khoury, et al [31] 3% Andersson, et al [32] 2 (3%) Bringman, et al [33] 2 (2%) Colak, et al [34] 4 (6%) Lal, et al [35] Eklund, et al [36] 5 (1%)

McCormack K: Cochrane systematic review 1. Duration of operation More Mean duration 14.81 min 2. Hematoma Fewer OR= 0.72 (0.60-0.81) 3. Risk of Seroma Higher OR= 1.58 (1.20-2.08) 4. Wound infection Less OR= 0.45 (0.32-0.65) 5. Mesh (deep) infection 3 cases 1 TAAP, 1 Open, 1 Open non mesh 6.Vascular injuries Intra Op 3 cases in Laparoscopic Post Op. 4 cases in Laparoscopic 4 cases in Open repair 7.Visceral injuries 6 in Laparoscopic 1 in Open repair 8. Time to return to usual activity Shorter HR=0.56 (0.51-0.61) 9. Persisting pain OR=0.54 (046-064) 10. Persisting numbness OR=0.38 (0.28-0.49) 11. Recurrence Lap: 86/3138 Vs Open: 109 /3504

Treatment of Recurrent inguinal hernia 1. Wound infection Less 2. Time to return to usual activity Shorter 3. Recurrence Comparable 4. Persisting pain 5. Hospital stay Overall Laparoscopic surgeries have better outcome than Open repair Li J et al. 2014 Am J Surg

Alexander am Surg Clin North Am. 2013 1. Wound infection Less 2. Recurrence Fewer 3. Persisting pain 4. Time to return to usual activity Overall Laparoscopic surgeries have better outcome than Open repair

Other evidences Author Type of evidence Year Conclusion Cavazzola LT Review 2013 Lap. Better Fabozzi RCT LVHR is better Kaoutzanis 2012 Lap. is better Vijfhuize S Open review Bracale U Lap. Better than OHR Bittner R Yang C Syst. Review & MA 2011 Lap. Better in pediatric Sauerland S MA Tong WM Better in component seperation Garcia-Vallejo L Lap. Better for Parastomal hernia Patle NM 2010 Lap. Better in Spigelian Hernia Wauschkunn Lap. Better for BL hernia repair Karthikesalingam Forbes SS 2009 Equivocal. Lap. = OHR

Midline Dissection

Lateral dissection & Second Port Insertion

Complimentary medial dissection

Dissection of Sac

Parietalisation of cord

Mesh Deployment

Conclusion Detailed anatomical knowledge, refined surgical technique, and experience are the decisive factors in successful treatment of inguinal hernia by laparoscopic means. Surgeons should be aware of indications & contra indications for lap repair, because some hernias should have laparoscopic repair. Prospective randomised trials have proven that laparoscopic hernia repair can be performed with a low incidence of recurrence and complications. Post operative pain and disability is less than after anterior repair. TEP has advantage of not violating the peritoneal cavity. Yes, lap repair of inguinal hernia is definitely needed and surgeon must learn the art of offering the best available options to his patients.