1. Repair of Inguinal Hernia: Open or Laparoscopic
Dr. YH Ling
Department of Surgery
Ruttonjee and Tang Shiu Kin Hospitals
17 April 2004

2. Evolution of techniques
Tension creating tissue suturing repair
Bassini
Cooper / McVay
Shouldice
Tension free mesh repair
Lichtenstein
Mesh plug
Laparoscopic repair
Transabdominal preperitoneal repair (TAPP)
Total extraperitoneal repair (TEP)

3. Recent trend ( )
A companion to specialist surgical practice , general and emergency surgery p.86

4. Tension Free Mesh Repair
Lichtenstein and Shulman 1987
Procedure under LA
Use of a sheet of 5cm x 10cm prosthetic mesh to reinforce the posterior wall of inguinal canal

5. Laparoscopic Hernia Repair
First described in early 1990s
Different methods
Ring hernioplasty
Mesh and plug
Intraperitoneal Onlay of Mesh (IPOM)
Transabdominal preperitoneal repair (TAPP)
Total extraperitoneal repair (TEP)

6. Meta-analysis
5 meta-analyses found in MEDLINE search in the last decade
Compare laparoscopic repair with open repair

7. Meta-analysis Author (year) No. of trials No. of patients Repair type
EU Hernia Trialists Collaboration
(Ann Surg Mar 2002) 58
11,000
Lap vs Open Mesh
Mesh vs non-mesh
Open mesh: flat vs plug vs preperitoneal
EU Hernia Trialists Collaboration (Hernia Mar 2002) 25
4,165
Lap vs Open
Memon 2003 29
5,588
Chung 1999 14
2,471
Lap vs Open
Voyles 2002 27
4,688

8. Meta-analysis: Laparoscopic vs Open
Author (year)
Recurrence
Operation time
Post-op pain
EU Hernia Trialists Collaboration
(Ann Surg Mar 2002)
(Lap vs open mesh)
Similar
Not studied
Lap: less
(Hernia Mar 2002)
Lap: longer
Memon 2003
Lap: higher
(not significant)
Chung 1999
Voyles 2002

9. Meta-analysis: Laparoscopic vs Open
Author (year)
Post-op Complications
Hospital stay
Time to return to work
Costs
EU Hernia Trialists Collaboration
(Ann Surg Mar 2002)
Not studied
EU Hernia Trialists Collaboration (Hernia Mar 2002)
Lap:
rare but serious
Lap: less
Memon 2003
Lap: shorter
Chung 1999
Voyles 2002
Lap > open

10. Meta-analysis: Conclusion
Laparoscopic repair
Similar recurrence rate as open repair
Less post-op pain
Faster return to work
Longer operation time

11. Meta-analysis
Increase use of tension free mesh repair in late 1990s

12. Meta-analysis
Tension free mesh repair has a lower complication rate and shorter convalescence period then tissue suture repair (Kark 1995)
Most meta-analyses are not comparing open mesh repair and laparoscopic repair

13. RCT: Open mesh vs Laparoscopic repair
MEDLINE search from
Favor Laparoscopic Repair
Wellwood 2003
Douek 2002
Bodil Andersson 2003
Favor Open Mesh Repair
Marcello Picchio 1999
Paganini 1998

14. RCT: Open mesh vs Laparoscopic repair
Diversity of results in different studies concerning
Post-op pain
Complications rate
Operation time
Time to return to work

15. RCT: Open mesh vs Laparoscopic repair
Heterogeneous study design
Sample size:
Subjective endpoints not reported in a standard, quantified manner
Post-op pain
Return to normal activity
Calculation of cost (direct and indirect)
Wide range of FU period
4 weeks to 5 years
 Difficult to draw accurate conclusions

16. RCT: Open mesh vs Laparoscopic repair
Wellwood et al 1998 UK
RCT
n=400
Lichtenstein (under LA) vs TAPP (under GA)

17. RCT: Open mesh vs Laparoscopic repair
Wellwood et al 1998 UK
Results:
Laparoscopic repair
Less post-op pain
Fewer complications, except of urinary retention
Better patient’s perception of health at 1 month
Shorter period of convalescence
Higher hospital cost

18. NICE recommendation
“First time hernias of the groin ought to have open repairs and that laparoscopic (TEP) repair should only be considered for bilateral and recurrent hernias and be performed in specialist units.”
Jan 2001

19. Open mesh repair Laparoscopic repair Anaesthesia LA Obligatory GA
Patient selection
Age, physical infirmity, co-morbid condition not rejected
Not suitable for those with co-morbidity and cardiopulmonay diseases
Operation time
Shorter
Longer
Learning curve
Short
Long

20. Rare but potential serious complications:
Open mesh repair
Laparoscopic repair
Complications
Minimal
Rare but potential serious complications:
Bowel injury
Bladder injury
Major vessel injury
Return to work and daily activities
Early
Earlier
Hospital expense
Low
High GA
Instruments
Longer OT time

21. Summary
There is an increase use of tension free mesh repair e.g. Lichtenstein repair in late 1990s
Meta-analyses and RCT cannot draw accurate conclusion on whether open mesh or laparoscopic repair is more favorable

22. Summary
Large scale RCT is need to evaluate the advantages and shortcomings of both techniques

23. Summary Leigh Neumayer et al RCT in progress n = 2165
FU period: 2 years
Outcome measures:
Recurrence
Complications
Patient centered outcomes
Cost

24. Our Experience Jan 2002 – Sep 2003 220 elective inguinal hernia repair
95% male patients
13% bilateral inguinal hernia
6.4% recurrent hernia

25. Age distribution
Average age: 67
Range: 17-90

26. Type of technique
217 (98.6%) Lichtenstein repair

27. Anaesthesia
GA/SA: 55 (25%)
LA: 162 (75%)

30. Length of Hospital Stay