1. Laparoscopic Repair of Inguinal Hernia – Is it really needed

2. 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

3. 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)

4. 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

5. 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”

6. 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 ( ). 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”

7. Hernia trusses

8. Eighteenth century Better information of anatomy
Antonio Scarpa ( )
Albert von Haller ( ) Congenital hernia
Percival Pott anatomy of congenital hernia
Pieter Camper ( )- Camper’s fascia
John Hunter ( ) – presence of process vaginalis & gubernaculum testis
Franz Hesselbach ( ) Hesselbach’s triangle

9. Sir Astley Cooper ( )
“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

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

11. 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

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

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

14. Lichtenstein Repair
Tension free repair
Use of prosthetic graft

15. 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.

16. Myopectineal orifice of Fruchaud

18. 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

19. Why so many modifications
Recurrence
Chronic pain

20. 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 TEP

21. 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.

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

23. 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

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

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

26. 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]

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%)

28. 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]

29. 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]

30. 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

31. 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]

32. 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]

33. 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%)

34. McCormack K: Cochrane systematic review
1. Duration of operation
More
Mean duration min
2. Hematoma
Fewer
OR= 0.72 ( )
3. Risk of Seroma
Higher
OR= 1.58 ( )
4. Wound infection
Less
OR= 0.45 ( )
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 ( )
9. Persisting pain
OR=0.54 ( )
10. Persisting numbness
OR=0.38 ( )
11. Recurrence
Lap: 86/3138 Vs Open: 109 /3504

35. 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 Am J Surg

36. 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

37. 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

38. Midline Dissection

39. Lateral dissection & Second Port Insertion

40. Complimentary medial dissection

41. Dissection of Sac

42. Parietalisation of cord

43. Mesh Deployment

44. 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.