ACS Surgery: Principles and Practice

Since its first description in 1990,1 laparoscopic inguinal herniorrhaphy has shown a great deal of promise; however, concurrently with its development, open anterior herniorrhaphy has evolved into a tension-free, mesh repair that is easily performed with the patient under local anesthesia and that is also associated with rapid recovery and low recurrence rates [see 5:27 Open Hernia Repair].2,3Thus, the key question about laparoscopic inguinal hernia repair at present is whether it provides a significant advantage over the tension-free open repair now in use. The two most common techniques for laparoscopic inguinal hernia repair involve the insertion of mesh into the preperitoneal space; one makes use of a transabdominal preperitoneal (TAPP) approach, the other a totally extraperitoneal (TEP) approach. Both approaches would appear to offer potential advantages, such as reduced postoperative pain, shortened recovery, quicker and more accurate assessment and repair of bilateral groin hernias simultaneously, and, in the case of recurrent hernia, avoidance of previously dissected and technically difficult scarred areas. In practice, however, the advantages are not invariably realized; a laparoscopic approach is not always minimally invasive, and various disadvantages accrue from the current requirement for general anesthesia, the need to traverse the abdominal cavity in the TAPP technique, and the increase in operating room time and costs.4 Meticulous attention to surgical technique is essential. Because surgeons may be unfamiliar with inguinal anatomy as viewed from inside the abdomen and because the potential for complication necessitating laparotomy is increased with the laparoscopic approach, surgeons must be proficient in laparoscopic techniques and must have a precise knowledge of anatomic relations in the region of the groin as seen from the peritoneal surface. Since the late 1990s, laparoscopic video techniques have also been increasingly applied to the repair of incisional hernias.5-9 Laparoscopic repair of large incisional hernias resembles open repair in that mesh is inserted to cover the defect in the abdominal wall fascia [see 5:27 Open Hernia Repair]. A laparoscopic approach is theoretically attractive because an open approach usually necessitates a large incision as well as extensive and tedious wide dissection to expose the abdominal wall defect, resulting in considerable postoperative pain and a risk of wound complications—problems that a laparoscopic approach to the defect from within might minimize. It may be many more years before the true safety and efficacy of laparoscopic herniorrhaphy can be determined and the correct indications for its use established. In the meantime, every repair performed should be subjected to careful classification, documentation, and quality-of-life assessment. Surgeons should not perform laparoscopic herniorrhaphy simply because it is relatively new or potentially economical; they should perform it only when convinced that it is anatomically and physiologically correct and logical. In what follows, we discuss laparoscopic repair of both inguinal and incisional hernias. In addition to describing current operative techniques, we address inguinal surgical anatomy, preoperative planning, and complications. Finally, we review selected trials measuring the results of laparoscopic repair against those of open repair and comparing the outcomes of TAPP repair with those of TEP repair.