LAPAROSCOPIC INGUINAL HERNIA REPAIR Jeffrey S. Bender, MD, FACS University of Oklahoma College of Medicine

Objectives Appreciate the history and evolution Understand the various approaches Have knowledge of the complications and outcomes Not an attempt to teach how

Inguinal Hernia – The Problem Very common Recurrence rates still as high as 15% Increased recognition that mesh necessary “Tension-free” repairs

Laparoscopic Hernia Second most common laparoscopic procedure Initial enthusiasm now tempered Technically more difficult than laparoscopic cholecystectomy Patient demand not as great

History First performed with clips 1979 (Ger) Didn’t become popular until laparoscopic cholecystectomy Initial series (1990) reported plug only Plug migration a problem: fixation

History (cont) Plug: recurrence rate of 25% Realization that patch necessary Recognition of defect in transversalis fascia Three currently used techniques

Transabdominal Preperitoneal Herniorrhaphy (TAPP) First reported 1991 Closure of peritoneum required Easier to learn Risk of bowel injury

Intraperitoneal Onlay Mesh Herniorrhaphy (IPOM) First reported 1992 Technically the easiest (no retro-peritoneal dissection) Anecdotal: adhesion of bowel to mesh Not a problem in only large series published

Totally Extraperitoneal Herniorrhaphy (TEPP) First reported 1993 Similar to Stoppa technique Avoid bowel injuries Learning curve reportedly more difficult

Early Results 444 repairs in 375 patients, 1991-1994 Mostly TEPP; single surgeon Recurrence rate 0.7% Overall complication rate 2.0% Two operations for SBO Fielding Aust NZ J Surg, 1995

Early Results 869 hernias in 686 patients, 1991-1992 ¾ TAPP, ¼ IPOM, multi-institutional Recurrence rate 4.5% Overall complication rate 17.1% One bowel perforation, one bladder injury, one SBO Fitzgibbons, et al. Ann Surg, 1995

Early Results 600 repairs in 493 patients, 1991-1994 ½ TAPP, ½ TEPP, single institution Recurrence rate 1.2% (TAPP > TEPP) Overall complication rate 2.0% 3 bowel injuries, 2 bladder injuries, 1 SBO (port) Ramshaw, et al. Surg Endosc, 1996

Summary of Early Results Effective repair Probable shorter convalescence No long term data Serious complications in 2-4:1000

Randomized Trial #1 487 TEPP vs. 507 open, 1994-1995 One year follow-up 6 wound infections open vs. 0 in TEPP (p=0.03) TEPP had quicker recovery, back to work, etc.

Randomized Trial #1 Recurrence: 6.0% open vs. 3.0% TEPP (p=0.05) 24 conversions to open operation in laparoscopic group 7 major hemorrhage in laparoscopic group vs. 2 in open group Open operation not standardized (only 3% had mesh) Liem, et al. NEJM, 1997

Randomized Trial #2 496 laparoscopic vs. 460 open One year follow-up Complications: 29.9% lap vs. 43.5% open (p=.001) Return to activity: 10 days lap vs. 14 days open (p=.004)

Randomized Trial #2 Persistent groin pain: 28.7% lap vs. 36.7% open (p=.018) Recurrence: 1.9% lap vs. 0.0% open (p=.017) 3 major complications in laparoscopic group MRC Group Lancet, 1999

Randomized Trial #3 989 laparoscopic (90% TEPP) vs. 994 open, 1999-2001 Two year follow-up Complications: 39.0% lap vs. 33.4% open 2 port site hernias, 2 major bleeds in laparoscopic group

Randomized Trial #3 3 deaths in laparoscopic group (1 bowel injury) 1 death in open group Return to activity: 4 days lap vs. 5 days open Laparoscopic had less pain

Randomized Trial #3 Primary recurrence: 10.1% lap vs. 4.0% open Recurrent recurrence: 10.0% lap vs. 14.1% open, p=n.s. 250 lap hernias necessary to reduce recurrence rate Open recurrence rate not altered by experience Neumayer et al. NEJM, 2004

Summary Laparoscopic herniorrhaphy likely less painful Short term outcomes comparable Long term outcomes unknown Small, but real serious complication rate Experience is key

Current Practice Discuss, but don’t propose for primary Good option for recurrent (especially early) or bilateral Possible advantage in obese High index of suspicion for complications