1. Laparoscopic versus Open Inguinal Hernia Repair
Michael J. Rosen MD, FACS
Chief, Division of Gastrointestinal and General Surgery
Director, Case Comprehensive Hernia Center
University Hospitals of Cleveland
Case Western Reserve Medical Center,
Cleveland, Ohio

2. Objective What is an open inguinal repair
What is a laparoscopic inguinal hernia repair
What are reasonable outcome variables we should be using to compare these two techniques
What is the data?
WHAT SHOULD YOU BE DOING?

3. Take Home Message
There is no perfect operation for repairing inguinal hernias.
Excellent long term results are often more difficult to achieve then we admit.
Probably the best operation for your patient is the one you do best.

4. Controversies in Inguinal Hernia Repair
Repair or no repair?
Mesh or no mesh?
What kind of mesh?
Open or laparoscopic?
Extraperitoneal or intraperitoneal?
Despite how common inguinal hernia repairs are the surgeon is faced with many unanswered questions in choosing the best procedure for their patients.
First question is should an asymptomatic hernia even be fixed at all, in an elderly patient, probably not, younger patients I do fix them..

5. What is an open inguinal hernia repair?
Tissue repairs
Mesh repairs

6. Bassini repair 1887, McVay repair 1958, Shouldice repair 1940’s
Tissue Repair

7. Prosthetics

8. “These are anterior repairs”

11. Mesh or no mesh? EU Hernia Trialists Collaboration Meta-analysis
58 Trials
11,174 patients
Recurrence Rates
Mesh repair 2.0%
Non Mesh repair 4.9%

12. Laparoscopy
Laparoscopy early 1990’s

13. Types of laparoscopic inguinal hernia repairs
IPOM: Intra-Peritoneal Onlay Mesh repair
TAPP: Trans-Abdominal Pre-Peritoneal repair
TEP: Total Extra-Peritoneal repair

14. Anatomical Considerations of Inguinal Hernia Repair
Hernia sac reduction
Myopectineal orifice
Inguinal nerve anatomy

19. What are the appropriate outcome variables
Recurrence
Postoperative recovery
Cost
Groin pain
Learning curve

20. Recurrence Physical exam Ultrasound CT History Asymptomatic
Cord Lipoma
Complete follow up????

21. Postoperative recovery
Discharge from hospital
Return to work
Self employed
Factory worker on disability
“Feeling better”
Return to full activity 85 vs 25 yo
Activity restrictions

22. Cost To patient To surgeon To hospital To surgery center
Indirect Costs
Direct Costs
To Society

23. Groin Pain

24. Groin Pain At rest During full activity Foreign body sensation
Severe disabling pain
Specific questionnaire
Sought out, or wait to determine if patient complains

25. Learning Curve Understanding inguinal anatomy
Anterior
Posterior
Two handed laparoscopic skill set
Only if doing redo’s and bilateral
? Harder group?

26. THE DATA

27. Lichtenstein 4000 cases 4 recurrences Complications minor
<1% infection, seroma, hematoma
1 testicular atrophy
1 Chronic Neuralgia
Amid, Shulman, Lichtenstein; Surgery Today 1995

28. Mesh Plug (PerFix) 2403 repairs Recurrences Complications
2060 Primary repairs and 343 recurrent
Recurrences
3 (0.14%) Primary
8 (2.3 %) Recurrent
Complications
Urinary retention 0.3%
Rutkow and Robins

29. TAPP Results Phillips et al. Surg Endosc 95
1944 laparoscopic TAPP procedures
Complication No.
Recurrence (1%)
Complications (7%)
Hematoma
Neuralgia
Urinary Retention 20
Testicular Pain 11
Chronic Pain 6
SBO
Vasc. Injury 1

30. Technique Comparison Telik et al. 1994
1514 hernia repairs…..recurrence
TAPP %
TEP %
IPOM %
Plug & Patch %

31. TAPP vs TEP Millikan et al. 1994 Prospective randomized trial
60 TAPP, 60 TEP
Recurrence rate - overall 1.7%
TAPP 3.4% TEP 0.0%
Ramshaw et al. 1996
300 TAPP, 300 TEP
Recurrence 2.0% TAPP, 0.3% TEP
Complications: 2 enterotomies in TEP (prior incisions)

32. Laparoscopic vs. Open Randomized Controlled Trial

33. Evidence 507 open versus 487 Laparoscopic More infections in open 1%
More pain in open
More seroma’s and hematoma’s in Lap
Faster return to normal activites in Lap Group
PROBLEM: only 3% of open inguinal hernias were tension free

34. Laparoscopic versus Open Randomized Controlled Trial

35. VA Trial 14 VA hospitals 2164 Patients
1696 completed 2 years of follow up

36. Methods All repairs used mesh Open – Lichtenstein Laparoscopic 90% TEP
10% TAPP
Mesh size not standardized
Some mesh split, some not

37. Methods Patients followed for two years
Physical exam performed by blinded surgeon
When recurrence detected it was confirmed by independent Surgeon

38. Results Recurrence In recurrent Hernia repair Open 41/834 4.9%
Lap 87/ %
In recurrent Hernia repair
Open 11/ %
Lap 8/ %

39. Lap vs. Open “Experienced Surgeons”…
Primary Repairs Recurrence at 2 years
Open %
Laparoscopic 5.1%
Recurrent Hernias Recurrence at 2 years
Open %
Laparoscopic 3.6%
Neumayer et al. NEJM 2004; 350:

40. Results
Less Experienced Surgeons
Primary repair
Lap 12.3 %
Open 2.5 %

41. Learning Curve Lap Chole 50 cases Lap Gastric Bypass 75 – 100
Lap Hernia 250 ???

42. Results Complications 36% Open 33.4 Lap 39.0
Intraoperative, Immediate postoperative and Life threatening complications significantly higher in Lap Patients

43. Results Pain Daily Activities Sexual Activity Lap less painful
Lap 4 days Open 5 days
Sexual Activity
14 days both groups

44. VA Trial Analysis
Outcome Measures
Surgical Costs
Postoperative Costs
Quality adjusted life years (QALY)
Incremental cost per QALY gained

45. QALY Quality adjusted life years Life expectancy + Quality of Life
Less pain, early return to normal activities favorable
Complications and recurrence rate have negative effect
0= death
1= perfect health

46. Incremental Cost Effectiveness Ratio
The cost of an additional year of life gained in perfect health
Most insurers and payers agree that $50,000 is acceptable

47. Results Laparoscopic operative costs QALY and ICER
$638 dollars more then open
QALY and ICER
Unilateral Lap- Cost effective
Unilateral Recurrent Lap-Cost effective
Bilateral Lap- Not cost effective

48. TEP versus Lichtenstein Randomized Controlled Trial
Eker HH
Presented at American Surgical Association
2010 meeting
N=660
Erasmus Medical Center
Rotterdam Netherlands
Outcome: post op pain, recurrence, complications

49. Results TEP Complications more common with TEP
Less post op pain until 6 weeks
Reduced inguinal sensibility (7% v 30%)
Faster recovery of daily activities
Less absence from work
Complications more common with TEP
6% v 2%
Recurrence and Costs EQUAL
Mean follow up 66 months

50. Cochrane Database Review Laparoscopic versus Open Inguinal Hernia
41 published trials
7161 patients
Sample size
Follow up 6 weeks to 36 months
McCormak et al. Cochrane Database Syst Rev 2003

51. Cochrane Review Results
Longer OR times for Laparoscopic
Complications
Visceral injuries Lap 0.3% Open 0.04%
Vascular injuries Lap 0.3% Open 0.2%
Length of Stay no different
Return to full function quicker for laparoscopic

52. Cochrane Review Results
Persistent Pain
Lap 14% Open 19%
Persistent Numbness
Lap 7% Open 13%
Recurrence Rate (p=0.16)
Lap 3% Open 3%

53. Lessons
Laparoscopic repair has less pain and quicker return to daily activity
Comes with a cost
Higher recurrence rate
Higher major complication rate
Very high Learning Curve

54. What should you do? Primary Unilateral Inguinal Hernia
Open tension free
Laparoscopic inguinal is acceptable
Might be appropriate to overcome learning curve with more straight forward cases
Watch recurrence rates carefully
Makes more sense in young patients who will benefit from early return to full activity

55. What should you do? Bilateral or Recurrent Inguinal Hernia
Open approach is acceptable if laparoscopic is not available
Laparoscopic approach is ideal if you have the skills and experience

56. What should you do? Bottom line:
The safest most durable repair you can.