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    TEP TEP Presentation Transcript

    • TEP
    • TEP introduction
    • Epidemiologic, economic and sociologic aspects of hernia surgery in the United States in the 1990s. Rutkow IM (1998) Surg Clin North Am 78: 941–951
      • More than 700,000 groin hernia repairs are performed in the United States annually, approximately 100,000 for recurrence .
    • Laparoscopic repair of recurrent hernias M. A. Memon,1 X. Feliu,2 E. F. Sallent,2 J. Camps,2 R. J. Fitzgibbons, Jr.3 Surg Endosc (1999) 13: 807–810
      • A national study in 1983 by the Rand Corporation [24] and data from the National Center for Health Statistics, Hyattsville, Maryland [13] revealed that approximately 10% to 15% of all the inguinal herniorrhaphies (i.e., between 50,000 and 110,000) are performed to treat recurrent hernias.
      • 13. Memon MA, Rice D, Donohue JH (1997) Laparoscopic herniorrhaphy. J Am Coll Surg 184: 325–335
      • 24. Rubenstein RS, Beck S, Lohr KN, Kamberg CJ, Brook RH, Goldberg GA (1983) Conceptualization and measurements of physiologic health for adults. 15: 1–120
    • Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies Maurice E. Arregui1  and Susan B. Young1 World Journal of Surgery Société Internationale de Chirurgie 2005 10.1007/s00268-005-7968-9
      • Rutkow estimated that in 2003 in the United States, of approximately 800,000 groin hernia repairs 14% were performed laparoscopically
      • Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg. Clin. North Am. 2003;82:1045–1051
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
      • Currently, laparoscopic herniorrhaphy accounts for 15% to 20% of hernia operations in America and around the world.
      • For Laparoscopic radical prostatectomy or laparoscopic pelvic lymphadenectomy, previous TEP or TAPP with mesh placement have been considered a relative contraindication to laparoscopic surgery or a reason for the conversion to open surgery.
      • Rassweiler J, Sentker L, Seemann O, Hatzinger M, Rumpelt HJ (2001) Laparoscopic radical prostatectomy with the Heilbronn technique: an analysis of the first 180 cases. J Urol 166:2101–2108
      • Raboy A, Adler H, Albert P (1997) Extraperitoneal endoscopic pelvic lymph node dissection: a review of 125 patients. J Urol 158:2202–2204
    • Groin Hernia Repair: Open Techniques Parviz K. Amid1, 2 World Journal of Surgery June 2005
      • Mesh placement behind the transversalis fascia in the preperitoneal space (spaces of Retzius and Bogros), has led to growing concern among urologists and vascular surgeons about the extreme risk and difficulty, if not impossibility, of performing urologic and vascular operations—in particular, radical prostatectomy and lymph node dissection—subsequent to open and laparoscopic preperitoneal hernia repair .
      • Katz EE, Patel RV, Sokoloff MH, et al. Bilateral laparoscopic inguinal hernia repair can complicate subsequent radical retropubic prostatectomy. J. Urol. 2002;167:637–638
    • Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies Maurice E. Arregui1  and Susan B. Young1 World Journal of Surgery Société Internationale de Chirurgie 2005 10.1007/s00268-005-7968-9
      • The concept of GPRVS (great prosthetic replacement of the visceral sac) was developed by Nyhus, Stoppa for repair of difficult and recurrent inguinal hernias.
      • These hernias had a high recurrence rate that was reduced from more than 15% to less than 3%
      • Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron in the repair of hernias of the groin. Surg. Clin. North Am. 1984;64:269–285
    • Causes of recurrence after laparoscopic hernioplasty A multicenter study E. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7 Surg Endosc (1998) 12: 226–231
      • Nyhus et al. [12] and Stoppa et al. [26], demonstrated that the posterior placement of mesh is ideal even in the most difficult of circumstances , the recurrent hernia.
    • Endoscopic total extraperitoneal repair of primary and recurrent inguinal hernias M. T. T. Knook, W. F. Weidema,* L. P. S. Stassen, C. J. van Steensel* Surg Endosc (1999) 13: 507–511
      • Once a hernia has recurred after conventional herniorraphy, the result of every successive conventional repair will be worse, with an ultimate recurrence rate of 23–33% [14, 21, 27].
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • The advantages of TEP are more evident when it is applied to recurrent compared to primary hernias.
    • Totally Extraperitoneal (TEP) Approach for Inguinal Hernia: The Favorable Learning Curve for Trainees Jaime Haidenberg, MD, Michael L. Kendrick, MD, Tobias Meile, MD, and David R. Farley, MD CURRENT SURGERY • Volume 60/Number 1 • January/February 2003
      • TEP repair is a safe procedure effective in treating direct, indirect, pantaloon, and most importantly, recurrent and bilateral hernias through 3 small cosmetic incisions with early return to normal activities .
    • Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: a prospective randomized controlled trial. Andersson B - Surgery - 01-MAY-2003; 133(5): 464-72
      • Because many of the patients who undergo operation for hernia are of a working age, the treatment of inguinal hernia not only is of importance for the individual but also has great socioeconomic impact.
      • Laparoscopic techniques for inguinal hernia were introduced to reduce hernia recurrence and facilitate patient recovery and return to work.
    • Is Laparoscopic Inguinal Hernia Repair an Operation of the Past? Lorelei J Grunwaldt, MD, Steven D Schwaitzberg, MD, FACS, DavidW Rattner, MD, FACS, Daniel B Jones, MD, FACS American College of Surgeons Vol. 200, No. 4, April 2005
      • The recommendation of the National Institute of Clinical Excellence (NICE) states that open mesh repair should be the procedure of choice for primary inguinal hernia and that the laparoscopic approach should be limited to bilateral or recurrent hernia.6
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
      • Laparoscopic inguinal herniorrhaphy was first described by Ger, Schultz, Corbitt, and Filipi in the early 1990s [1–4]
      • Contraindications (relative and absolute) include previous lower abdominal surgery, pelvic radiation, previous extraperitoneal surgery (radical retropubic prostatectomy), and patients with impaired cardiac or pulmonary status who are not good candidates for general anesthesia.
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
      • Laparoscopic repair of recurrent hernias seems to make intuitive sense because the surgeon is dissecting through virgin tissue instead of old scar.
      • The laparoscopic repair of recurrent inguinal hernias can be done with low recurrence rates (0%–1.1%) [43–47], and several studies reported less pain and faster convalescence [44,48,49].
    • Totally extraperitoneal (TEP) hernia repair after an original TEP Is it safe, and is it even possible? G. S. Ferzli, K. Shapiro, S. V. DeTurris, P. Sayad, S. Patel, A. Graham, G. Chaudry Surg Endosc (2004) 18: 526–528
      • TEP repair of recurrent inguinal hernia after a primary TEP repair is entirely feasible technically as well as entirely safe.
    • Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy M. T. T. Knook,1 W. F. Weidema,2 L. P. S. Stassen,3 C. J. van Steensel2 Surg Endosc (1999) 13: 1145–1147
      • The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy.
    •  
    • TEP learning curve
    • Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: a prospective randomized controlled trial. Andersson B - Surgery - 01-MAY-2003; 133(5): 464-72
      • The learning curve for TEP is increased compared with both conventional hernia surgery 21 and TAPP.18
      • TEP has been suggested to be undertaken only by experienced laparoscopic surgeons who have performed more than 100 laparoscopic cholecystectomies. 21
      • 21. Liem MS, van Steensel CJ, Boelhouwer RU, Weidema WF, Clevers GJ, Meijer WS, et al. The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair. Am J Surg 1996;171:281-5.
      • 18. Kald A, Anderberg B, Smedh K, Karlsson M. Transperitoneal or totally extraperitoneal approach in laparoscopic hernia repair: results of 491 consecutive herniorrhaphies. Surg Laparosc Endosc 1997;7:86-9.
    • Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia Leigh Neumayer, M.D., Anita Giobbie-Hurder, M.S., Olga Jonasson, M.D., Robert Fitzgibbons, Jr., M.D., Dorothy Dunlop, Ph.D., James Gibbs, Ph.D., Domenic Reda, Ph.D., and William Henderson, Ph.D., for the Veterans Affairs Cooperative Studies Program 456 Investigators* n engl j med 350;18 29, 2004
      • The recurrence rate associated with laparoscopic repair was greater than 10 % for the 58 surgeons who reported having performed 250 or fewer laparoscopic repairs in any category,
      • The recurrence rate was less than 5 % for the 20 surgeons who reported having performed more than 250 laparoscopic repairs
      • For open repairs, there was no significant difference in the rate of recurrence between the most experienced group of surgeons (those who had performed more than 250 repairs) and surgeons with less experience
    • Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies Maurice E. Arregui1  and Susan B. Young1 World Journal of Surgery Société Internationale de Chirurgie 2005 10.1007/s00268-005-7968-9
      • The learning curve for a proper repair is greater than that of most laparoscopic procedures.
      • Although some have estimated that the learning curve is in the range of 30 to 50 procedures
      • Davis CJ, Arregui ME. Laparoscopic repair for groin hernias. Surg. Clin. North Am. 2003;83:1141–1161
      • The multiinstitutional Veterans Affairs study suggests that the number may be much higher [ 1 ].
    • Laparoscopic total extraperitoneal (TEP) inguinal hernia repair Overcoming the learning curve Pawanindra Lal, R. K. Kajla, J. Chander, V. K. Ramteke Surg Endosc (2004) 18: 642–645
      • We strongly recommend a minimum of 10 open Stoppa’s preperitoneal procedures, to enable a trained laparoscopic surgeon to start laparoscopic TEP operation independently and in the absence of another trained laparoscopic hernia surgeon, whose presence may not prevent complications and recurrences.
    • Totally Extraperitoneal (TEP) Approach for Inguinal Hernia: The Favorable Learning Curve for Trainees Jaime Haidenberg, MD, Michael L. Kendrick, MD, Tobias Meile, MD, and David R. Farley, MD CURRENT SURGERY • Volume 60/Number 1 • January/February 2003
      • In repairing over 2000 groin hernias over the past decade at an academic center, the senior author can attest that the TEP technique is conceptually easier to pass on to Mayo trainees than are modified Bassini, Lichtenstein, or mesh-plug techniques.
      • The duration of the operation and successful outcome (based on complications and recurrence) was no different among PG-1, 2, 3, 4, or 5 level residents performing the procedure under staff supervision.
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
      • Some investigators have addressed the subject and shown that as the surgeon becomes more experienced, operating times, conversions to an open procedure, complications, and recurrences all decrease [17,53–56].
      • It is not known precisely how many operations are required to attain proficiency, but 30 to 50 appears to be the range [17,54–56].
    •  
    • TEP technique
    • Totally extraperitoneal (TEP) hernia repair after an original TEP Is it safe, and is it even possible? G. S. Ferzli, K. Shapiro, S. V. DeTurris, P. Sayad, S. Patel, A. Graham, G. Chaudry Surg Endosc (2004) 18: 526–528
      • Our approach to these recurrences did not vary markedly from the standard TEP repair of primary hernia [3, 17].
      • The working space is very limited and balloon dissection should be avoided.
      • Every effort is made to use the three previous midline trocar incisions for access to the preperitoneal space.
      • A transverse incision was made in the anterior rectus fascia contralateral to the hernia.
      • The posterior rectus space was then developed in the midline using finger dissection staying very superficial and tangential to the rectus.
      • A Hasson cannula was placed and secured with skin stay sutures, and the preperitoneal space was insufflated with carbon dioxide to 10mmHg.
      • The linea alba was freed bluntly as far cephalad as possible and caudally enough to permit introduction of a second trocar — an 11-mm one on the midline, approximately 1cm below the first. This was used for sharp dissection of the preperitoneal space.
      • Then, a third trocar (5 mm) was placed approximately 1 cm below the second. The last two trocars were placed under direct vision.
    • Totally extraperitoneal (TEP) hernia repair after an original TEP Is it safe, and is it even possible? G. S. Ferzli, K. Shapiro, S. V. DeTurris, P. Sayad, S. Patel, A. Graham, G. Chaudry Surg Endosc (2004) 18: 526–528
      • If the contralateral posterior rectus space proved too difficult to open, the anterior rectus sheath was opened and the procedure continued on the same side as the hernia. However, in most cases this was not necessary.
      • Adhesions were taken sharply, without cautery.
      • Occasionally, midline adhesions were also taken sharply to free the preperitoneal space.
      • The midline pubic symphysis was identified, which helped avoid injury to the bladder and also made repair of inadvertent bowel and bladder injuries considerably easier.
      • In cases of contralateral hernia, the dissection proceeded without exposing the prior repair.
      • In sameside recurrences, adhesions were taken down posterior to the epigastric vessels prior to the midline Retzius space.
      • An attempt was made to dissect Bogros’ space. If this proved feasible, it was developed in this plane, and the posterior medial wall of the transversalis muscle and fascia was exposed.
      • When dense adhesions prevented adequate mobilization of the space posterior to the epigastric vessels, they were ligated to provide a safe working area by decreasing the chances of bleeding and aiding in better mesh placement.
      • A 6 · 6-in polypropylene mesh was used on all patients and none required a Foley catheter.
      • Small inadvertent peritoneal tears were left untreated if they did not obscure the operative field. Those larger than 2 cm were closed with a Vicryl Endoloop (Ethicon, Somerville, NJ, USA).
    • Endoscopic extraperitoneal radical prostatectomy in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair . Jens-Uwe Stolzenburg Æ Chris Anderson Robert Rabenalt Æ Minh Do Æ Kossen Ho Michael C. Truss World J Urol (2005) DOI 10.1007/s00345-005-0001-y
      • The port placements can be adjusted to compensate for the previous hernia repairs.
      • Out of these 750 patients who underwent EERPE, 14 had previous laparoscopic hernia repair with mesh placement; 8 patients had prior TEP (two bilateral) and 6 patients had prior TAPP. In one of the cases, who had bilateral prior TEP, the extraperitoneal space could not be created and the procedure was performed by a transperitoneal approach.
    • Endoscopic extraperitoneal radical prostatectomy in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair . Jens-Uwe Stolzenburg Æ Chris Anderson Robert Rabenalt Æ Minh Do Æ Kossen Ho Michael C. Truss World J Urol (2005) DOI 10.1007/s00345-005-0001-y
      • In about half of the patients with prior extraperitoneal mesh placement, the surgeon might encounter extreme difficulties in creating the extraperitoneal space.
      • The surgeon needs to expose the arch of the symphysis pubis, from the medial to the lateral side, by a blunt dissection on the opposite side of the mesh.
      • Using the midpoint of the symphysis as a point of reference, blunt and sharp dissections are performed in a craniad direction and remain on the ventral surface of the rectus muscle.
      • Further, similar dissection is carried out, from the medial to the lateral side in the direction of the iliac spine, once that level has been reached.
      • The previous mesh placement not only creates access problems but is also associated with a higher degree of technical difficulty in carrying out the dissection of the extraperitoneal space.
      • Consequently, early recognition and management needs to be applied to complications.
    • Endoscopic extraperitoneal radical prostatectomy in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair . Jens-Uwe Stolzenburg Æ Chris Anderson Robert Rabenalt Æ Minh Do Æ Kossen Ho Michael C. Truss World J Urol (2005) DOI 10.1007/s00345-005-0001-y Trocar placement in endoscopic extraperitoneal radical prostatectomy (EERPE): a) standard EERPEprocedure, b) previous left-sided mesh placement during minimally invasive inguinal hernia repair, and c) previous right-sided mesh placement during minimally invasive inguinal hernia repair
    • Causes of recurrence after laparoscopic hernioplasty A multicenter study E. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7 Surg Endosc (1998) 12: 226–231
      • Care must be taken to clear the iliopubic tract in order to ensure the removal of an extraperitoneal fat that may be draping over the internal ring into the canal.
    • Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy M. T. T. Knook,1 W. F. Weidema,2 L. P. S. Stassen,3 C. J. van Steensel2 Surg Endosc (1999) 13: 1145–1147
      • It is thought that all defects should be overlapped by 2 cm if the mesh is stapled and 3 cm if it is left unstapled.
      • A 15 × 15 cm prosthesis should therefore be adequate to prevent recurrent hernias, assuming that the mesh is positioned properly and complete dissection has been done [5, 11].
      • 11. Lowham AS, Filipi CJ, Fitzgibbons RJ, Stoppa R, Wantz E, Felix EL, Crafton WB (1997) Mechanisms of hernia recurrence after preperitoneal mesh repair: traditional and laparoscopic. Ann Surg 4: 422–431
    • Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies Maurice E. Arregui1  and Susan B. Young1 World Journal of Surgery Société Internationale de Chirurgie 2005 10.1007/s00268-005-7968-9
      • This requires in-depth knowledge of the preperitoneal anatomy as well as developing a firm spatial orientation in the preperitoneal location.
      • Structures in the preperitoneal space are covered with various fascial planes, which can be quite confusing. This is complicated by the generous layers of fat that serve to cushion the inguinal, pelvic, and retroperitoneal spaces.
      • Patience and meticulous dissection is required for a successful, safe repair.
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • The mesh must adequately cover all potential hernia sites even after the well-known 20% shrinking loss [1, 16].
    • Totally Extraperitoneal (TEP) Approach for Inguinal Hernia: The Favorable Learning Curve for Trainees Jaime Haidenberg, MD, Michael L. Kendrick, MD, Tobias Meile, MD, and David R. Farley, MD CURRENT SURGERY • Volume 60/Number 1 • January/February 2003
      • The principles of the TEP technique are sound: Tension-free permanent mesh covers all 3 groin hernia sites in a minimally invasive fashion.
      • Every move is done under full visualization.
      • And, the pearls of experience are relatively few and usually obvious: (1) leave the inferior epigastric vessels tethered anteriorly, (2) avoid dissection in the region of the iliac vessels, (3) release the hernia sac and peritoneum as far cephalad as possible, (4) never tack or staple the mesh below the iliopubic tract, and (5) tether the inferior portion of the mesh posteriorly as the pneumopelvis deflates.
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
      • it is imperative to dissect the myopectineal orifice and surrounding structures completely.
      • This means full exposure of the pubic bone medially and the space of Retzius, ‘‘removal of excess preperitoneal fat and cord lipomas, complete assessment of all potential hernia sites, full reduction of the direct sac, complete dissection of the proximal indirect sac from the cord and identification of the vas deferens and gonadal vessels’’ [10].
    •  
    • TEP complications
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
    • Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies Maurice E. Arregui1  and Susan B. Young1 World Journal of Surgery Société Internationale de Chirurgie 2005 10.1007/s00268-005-7968-9
      • Although overall complications may be the same as open repairs, the potential for serious injuries is higher with the laparoscopic approach.
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
      • Laparoscopic herniorrhaphy shares some complications with the open technique but also has its own set of complications.
      • Some of these problems were encountered early on and were corrected as surgeons became more experienced with the technique.
      • The incidence of complications has decreased with time [62,67].
      • In an interesting analysis of their experience, Felix et al found a 2.7% complication rate over a 6-year period, but when the data was broken down into two 3-year periods, their complication rate of 5.6% for the first 3 years dropped to 0.5% in the second 3 years.
      • They also found that 90% of the complications occurred in the first 50% of patients [67].
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
      • Urinary retention, a complication of open repair as well, was the most common of the patient related problems, with an incidence of 1.3% to 5.8% [57,62,66]
      • Testicular problems include pain, swelling, and orchitis, and occur in 0.9% to 1.5% of cases. Most are transient.
      • laparoscopic repair compares favorably with the open repair in a number of areas—vascular injuries, testicular problems, seromas, and hydrocele [66].
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • The incidence of peritoneal defects associated with TEP depends on the presence of a recurrence and prior infraumbilical abdominal surgery (particularly appendectomy).
      • The corresponding data in the literature vary between 24 and 31%, with a substantially lower percentage of recurrent hernias in some cases [17, 20, 22].
    • Endoscopic totally extraperitoneal inguinal hernioplasty for recurrence after open repair. Lau H . J Laparoendosc Adv Surg Tech A. 2004 Apr;14(2):93-6.
      • The incidence of peritoneal tear in the recurrent group (46%) was significantly higher than that of the control group (28%) (P < 0.05).
      • Early and late outcomes of TEP for recurrent inguinal hernia were equivalent to those for primary inguinal hernia but a higher incidence of peritoneal tear (46%) was encountered during TEP for recurrent inguinal hernia.
    • Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia Leigh Neumayer, M.D., Anita Giobbie-Hurder, M.S., Olga Jonasson, M.D., Robert Fitzgibbons, Jr., M.D., Dorothy Dunlop, Ph.D., James Gibbs, Ph.D., Domenic Reda, Ph.D., and William Henderson, Ph.D., for the Veterans Affairs Cooperative Studies Program 456 Investigators* n engl j med 350;18 29, 2004
      • The rate of complications was higher in the laparoscopic-surgery group than in the open-surgery group (39.0 percent vs. 33.4 percent )
    • Totally extraperitoneal endoscopic inguinal hernia repair (TEP) Results of 5,203 hernia repairs C. Tamme, H. Scheidbach, C. Hampe, C. Schneider, F. Ko¨ ckerling Surg Endosc (2003) 17: 190–195
      • Regarding intraoperative complications, we observed eight injuries to the bladder.
      • Postoperatively, we noted only a single case of mesh infection.
      • In 14 cases (0.4%), postoperative hemorrhage necessitated either inguinal or endoscopic reoperation.
      • As a further major complication, a small bowel obstruction caused by inadequate closure of a peritoneal lesion occurred in two patients (0.05%).
      • The overall reoperation rate for the 3,868 patients was 0.6%.
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • A total of 179 patients with recurrent inguinal hernia were recruited.
      • the inadvertant opening of the peritoneum in 26.3% of the patients.
      • Intraoperative complications developed in 4 patients (2.3%), including one injury to the bladder and three cases of bleeding from side branches of the epigastric vessels.
      • The conversion rate was 0%.
    •  
    • TEP recurrences
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
    • Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Rutkow IM, Robbins AW (1993) Clin North Am 73: 413–426
      • Primary repair has been associated with recurrence rates as high as 10–15% .
    • Causes of recurrence after laparoscopic hernioplasty A multicenter study E. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7 Surg Endosc (1998) 12: 226–231
      • Only in isolated centers specializing in hernia repair have reported recurrence rates approached an acceptable level of <1% [3, 23].
    • Totally extraperitoneal (TEP) hernia repair after an original TEP Is it safe, and is it even possible? G. S. Ferzli, K. Shapiro, S. V. DeTurris, P. Sayad, S. Patel, A. Graham, G. Chaudry Surg Endosc (2004) 18: 526–528
      • Although rates appear to be lower with laparoscopy, there is still a measurable rate of recurrence after it (0.4–12%) [2, 7, 9, 19].
    • Causes of recurrence after laparoscopic hernioplasty A multicenter study E. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7 Surg Endosc (1998) 12: 226–231
      • recurrence (0.4%) .
      • As surgeons gained experience, the incidence of recurrence due to missed hernias or too small a mesh decreased.
    • Causes of recurrence after laparoscopic hernioplasty A multicenter study E. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7 Surg Endosc (1998) 12: 226–231
      • Recurrence rates after laparoscopic repairs, however, have varied widely between different series.
      • A few groups have reported short-term recurrence rates <1% [1, 5, 6, 11, 14, 31], whereas others have reported rates that range from 2 to 10% [4, 10, 16, 28, 30].
    • Causes of recurrence after laparoscopic hernioplasty A multicenter study E. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7 Surg Endosc (1998) 12: 226–231
      • The incidence of failure was 0.22% for all TEP repairs.
      • A retained or missed lipoma was responsible for one-third of the TEP repairs that failed.
      • When performing a totally extraperitoneal dissection, the surgeon may overlook a lipoma if there is no indirect hernia or the indirect hernia is quite small.
    • Causes of recurrence after laparoscopic hernioplasty A multicenter study E. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7 Surg Endosc (1998) 12: 226–231
      • The size of the mesh was rarely a cause of failure in TEP repairs.
      • Inadequate lateral fixation of mesh was one of the major causes of failure in 22% of TEP repairs.
      • To prevent lateral recurrences, several surgeons in our study utilized a keyhole in the mesh that placed it under the testicular vessels and vas deferens.
      • The keyhole, however, was responsible for one-third of the TEP failures.
    • Phillips EH, Rosenthal R, Fallas M, Carroll B, Arregui M, Corbitt J, Fitzgibbons R, Seid A, Schultz L, Toy F (1995) Reasons for early recurrence following laparoscopic hernioplasty. Surg Endosc 9: 140– 145
      • Recurrences are mainly due to: - insufficient mesh size - inadequate mesh positioning - mesh migration .
    • Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy M. T. T. Knook,1 W. F. Weidema,2 L. P. S. Stassen,3 C. J. van Steensel2 Surg Endosc (1999) 13: 1145–1147
      • The recurrence rate for endoscopic herniorraphy is low (0–3%)
    • Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy M. T. T. Knook,1 W. F. Weidema,2 L. P. S. Stassen,3 C. J. van Steensel2 Surg Endosc (1999) 13: 1145–1147
      • Factors that may lead to recurrences include: - the limitation of the surgeon’s experience - inadequate dissection - missed hernias - insufficient size of the prosthesis - insufficient overlap of the prosthesis over the hernial defect - improper fixation - folding or twisting of the prosthesis - mesh lifting secondary to hematoma formation
    • Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy M. T. T. Knook,1 W. F. Weidema,2 L. P. S. Stassen,3 C. J. van Steensel2 Surg Endosc (1999) 13: 1145–1147
      • The prevailing opinion is that recurrences are due to technical errors.
      • It has been shown that most recurrences occur during the surgeon’s early experiences with endoscopic hernia repair
    • Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy M. T. T. Knook,1 W. F. Weidema,2 L. P. S. Stassen,3 C. J. van Steensel2 Surg Endosc (1999) 13: 1145–1147
      • In the TEP procedure, incorrect positioning is the most probably cause of medial recurrence.
      • On the other hand, the mesh could have moved laterally during desufflation if it was not kept in place {11}.
      • After desufflation, when a hematoma or a seroma forms, floating of the mesh can lead to mesh movement.
      • Elevation of the intraabdominal pressure might lead to protrusion of the mesh into the hernial defect.
      • 11. Lowham AS, Filipi CJ, Fitzgibbons RJ, Stoppa R, Wantz E, Felix EL, Crafton WB (1997) Mechanisms of hernia recurrence after preperitoneal mesh repair: traditional and laparoscopic. Ann Surg 4: 422–431
    • Laparoscopic repair of recurrent hernias M. A. Memon,1 X. Feliu,2 E. F. Sallent,2 J. Camps,2 R. J. Fitzgibbons, Jr.3 Surg Endosc (1999) 13: 807–810
      • Recurrence after primary conventional inguinal herniorrhaphy occurs in approximately 10% of patients depending on the type of repair and expertise of the surgeon.
      • The repair of the resulting recurrent hernia is a daunting task because of already weakened tissues and obscured and distorted anatomy.
      • The failure rate of these repairs using an open anterior approach may reach as high as 36%.
      • Some of the earlier reports suggested a low recurrence rate of 0.5% to 5% when a laparoscopic approach was used to repair these hernias.
    • The cause, prevention, and treatment of recurrent groin hernia Lichtenstein IL, Shulman AG, Amid PK (1993). Surg Clin North Am 73: 529– 544
      • The actual number of recurrences may be underestimated because of (a) inadequate length of follow-up; (b) lost patients; (c) unreliable follow-up methods, especially the use of questionnaires or telephone interviews in which patients are not actually examined by the physician; (d) financial constrains for repeated physician follow-up; (e) great mobility of the population in the United States, (f) the false assumption that patients lost to follow-up will represent the same success ratio as those described in the statistics.
    • Totally extraperitoneal endoscopic inguinal hernia repair (TEP) Results of 5,203 hernia repairs C. Tamme, H. Scheidbach, C. Hampe, C. Schneider, F. Ko¨ ckerling Surg Endosc (2003) 17: 190–195
      • 29 recurrent hernias (0.6%) were observed, more than 50% of which occurred during the first 2 years after the technique was introduced (1.8%). During subsequent years, the recurrence rate settled to approximately 0.3%.
    • Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies Maurice E. Arregui1  and Susan B. Young1 World Journal of Surgery Société Internationale de Chirurgie 2005 10.1007/s00268-005-7968-9
      • A missed lipoma of the cord or subsequent herniation of preperitoneal fat may mimic recurrence. This usually occurs through the internal ring but can occur at the site of a previous direct hernia. This is difficult to prevent even with well placed mesh, as the fat can work its way between the mesh and the abdominal wall.
      • A seroma or hematoma, can cause discomfort or be mistaken for a recurrence.
    • Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies Maurice E. Arregui1  and Susan B. Young1 World Journal of Surgery Société Internationale de Chirurgie 2005 10.1007/s00268-005-7968-9
      • 314 hernia repairs with no true peritoneal recurrences and no serious or late complications.
    • Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies Maurice E. Arregui1  and Susan B. Young1 World Journal of Surgery Société Internationale de Chirurgie 2005 10.1007/s00268-005-7968-9
      • Table 1. Review of recent studies: recurrence and complication rates.
      • Study No. of patients Recurrence Complications
      • Minor Major
      • Schwab [16] 2002 (L) 1388 11 (0.6%) 83 (6.0%) 18 (1.3%)
      • Fazzio [11] 2002 (L) 408 1 (0.2%) 3 (0.74%) 0
      • Schmedt [18] 2002 (L) 5524 55 (1.8%) Total 202 (3.7%)
      • Ramshaw [10] 2003 (L) 337 1 (0.3%) 22 (6.5%) 0
      • Bell [19] 2003 (L) 186 1 (0.53%) 10 (5.4%) 0
      • Pawanindra [12] 2003 (L) 25 0 3 (12.0%) 0
      • Schneider [13] 2003 (L) 28 1 (3.6%) 5 (17.9%) 0
      • Winslow [15] 2004 (L) 147 3 (2.0%) 49 (33.3%) 0
      • Feliu [14] 2004 (L) 78 1 (1.3%) 12 (13.9%) 1 (1.3%)
      • Heikkinen [17] 2004 (L) 62 5 (8.0%) 0 1 (1.6%)
    • Groin Hernia Repair: Open Techniques Parviz K. Amid1, 2 World Journal of Surgery June 2005
      • shrinkage of the mesh in vivo, is approximately 20%.
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • Our re-recurrence rate related to 181 operated recurrent hernias is 0%.
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • In the beginning of our experience with TEP in 1994, the recurrence rate for the first 200 patients was 3%, presumably due to the lower level of operative experience and the use of a smaller mesh size (8 · 12 cm).
      • A number of investigations have reported low (<3%) or very low (<1%) recurrence rates for the minimally invasive techniques
      • For open, preperitoneal mesh repairs, the re-recurrence rates reported in the literature vary between 1.1 and 12.0% .
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • Recurrence and re-recurrence rates following inguinal hernia repair depend on: - the age and sex of the patient - the time elapsed since the first operation, - type of hernia, - operative approach, - the surgeon.
    • Is Laparoscopic Inguinal Hernia Repair an Operation of the Past? Lorelei J Grunwaldt, MD, Steven D Schwaitzberg, MD, FACS, DavidW Rattner, MD, FACS, Daniel B Jones, MD, FACS American College of Surgeons Vol. 200, No. 4, April 2005
    • Recurrent inguinal hernia: a ten-year review. Feliu X , Jaurrieta E , Vinas X , Macarulla E , Abad JM , Fernandez- Sallent E Hernia. 2005 May;9(2):120-4. Epub 2004 Oct 29
      • A prospective controlled study with 258 recurrent inguinal hernias in 235 patients over a ten-year period.
      • There were 3 recurrences (2.2%) in the LAP group
    • Totally Extraperitoneal (TEP) Approach for Inguinal Hernia: The Favorable Learning Curve for Trainees Jaime Haidenberg, MD, Michael L. Kendrick, MD, Tobias Meile, MD, and David R. Farley, MD CURRENT SURGERY • Volume 60/Number 1 • January/February 2003
      • Our overall recurrence rate is relatively low (2%),
      • it is important to note that of the 8 overall recurrences, 6 occurred in the first 40 cases when our technique involved placement of a 2.54-inch piece of permanent mesh and did not emphasize holding down the lower, lateral corner of the mesh upon evacuation of the CO2 gas.
    • Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161
      • The TAPP and TEP repairs faired much better, with recurrence rates of 0.7% and 0.4% respectively [57].
      • A review of 23 noncomparative trails of laparoscopic hernioplasty from 1992 to 1995, all with 100 or more patients, showed recurrence rates ranging from 0% to 4.5% [50].
      • The two most common causes of recurrence are incomplete dissection of the myopectineal orifice and inadequate size of the mesh.
      • Lowham et al [10] reviewed 13 videotapes of hernias that had recurred in the multicenter trial by Fitzgibbons et al [62] and found that incomplete dissection of the myopectineal orifice was the primary cause of recurrence.
    • Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia Leigh Neumayer, M.D., Anita Giobbie-Hurder, M.S., Olga Jonasson, M.D., Robert Fitzgibbons, Jr., M.D., Dorothy Dunlop, Ph.D., James Gibbs, Ph.D., Domenic Reda, Ph.D., and William Henderson, Ph.D., for the Veterans Affairs Cooperative Studies Program 456 Investigators* n engl j med 350;18 29, 2004
      • Recurrence was significantly more common after laparoscopic repair than after open repair of primary hernias (10.1 percent vs. 4.0 percent)
      • The rates of recurrence after repair of recurrent hernias were similar in the two groups (10.0 percent and 14.1 percent, respectively).
      • conclusions
      • The open technique is superior to the laparoscopic technique for mesh repair of primary hernias.
    • Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia Leigh Neumayer, M.D., Anita Giobbie-Hurder, M.S., Olga Jonasson, M.D., Robert Fitzgibbons, Jr., M.D., Dorothy Dunlop, Ph.D., James Gibbs, Ph.D., Domenic Reda, Ph.D., and William Henderson, Ph.D., for the Veterans Affairs Cooperative Studies Program 456 Investigators* n engl j med 350;18 29, 2004
      • Among repairs of recurrent hernias performed by highly experienced surgeons, fewer recurrences were recorded after laparoscopic repair (1 recurrence after 28 such repairs [3.6 %]) than after open repair (11 recurrences after 64 such repairs [17.2 %]
    • Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia Leigh Neumayer, M.D., Anita Giobbie-Hurder, M.S., Olga Jonasson, M.D., Robert Fitzgibbons, Jr., M.D., Dorothy Dunlop, Ph.D., James Gibbs, Ph.D., Domenic Reda, Ph.D., and William Henderson, Ph.D., for the Veterans Affairs Cooperative Studies Program 456 Investigators* n engl j med 350;18 29, 2004
      • This multicenter, randomized trial compared two tension-free, mesh-based hernia-repair techniques: the Lichtenstein open procedure and the laparoscopic procedure.
      • Overall, recurrence rates were higher among patients whose hernias were repaired by the laparoscopic technique.
      • (90% of patients in the laparoscopic group underwent total extraperitoneal repair).
      • The death of a patient from an unrecognized bowel injury followed a total extraperitoneal repair; a second postoperative death occurred after a massive pulmonary embolism.
      • 97 patients out of 989 in the laparoscopic group who underwent open repair. Only 45 of these (4.6%) were intraoperative conversions. In the other 52 patients, the decision to perform an open repair was made before entering the operating room.
    • Laparoscopic Inguinal Hernia Repair David W. Rattner, MD, FACS Steven D. Schwaitzberg, MD, FACS Lorelei J. Grunwaldt, MD Daniel B. Jones, MD, FACS Journal of the American College of Surgeons Volume 201 • Number 3 • September 2005
      • The 4.6% conversion rate in the VA study really gets our attention and that of most other surgeons who regularly perform laparoscopic hernia repairs.
      • Similarly, if one looks at the complications that truly bother patients in the VA study, one can see that neuralgia and orchitis were more common in the patients undergoing open repairs.
      • Although seromas account for a large percentage of the complications in the laparoscopic arm of this study, seromas are almost always asymptomatic and resolve with observation 95% of the time.
      • If seromas are not listed as a complication, then the overall complication rate, even in the VA study, is higher for patients undergoing open hernia repair than those undergoing laparoscopic repair.
      • We have additional concerns about the recurrence rate reported in the VA study and wonder if some of the “recurrences” seen in patients undergoing laparoscopic hernia repair were, in fact, seromas.
    • Recurrent hernia following endoscopic total extraperitoneal repair. Chowbey PK - J Laparoendosc Adv Surg Tech A - 01-FEB-2003; 13(1): 21-5
      • Between January 1996 and December 2001, 1193 TEP hernia repairs were performed in 694 patients. In six patients, the hernia recurred following endoscopic TEP repair within the same period. Four of these patients elected to undergo laparoscopic transabdominal preperitoneal (TAPP) repair of the recurrent hernia .
      • Medial recurrences developed in three of the four patients because of medial displacement of the mesh. One patient was found to have a missed indirect hernia sac.
      • All the patients who underwent laparoscopic TAPP repair had an uneventful recovery and are well at follow-up.
    •  
    • TEP discussion
    • Totally extraperitoneal (TEP) hernia repair after an original TEP Is it safe, and is it even possible? G. S. Ferzli, K. Shapiro, S. V. DeTurris, P. Sayad, S. Patel, A. Graham, G. Chaudry Surg Endosc (2004) 18: 526–528
      • Laparoscopic repair of hernia recurrence has been shown to be effective and durable [6, 9, 11].
      • Several authors have also reported successful TAPP repair for recurrence after primary laparoscopy (TAPP or TEP) [5, 7, 11].
    • Totally extraperitoneal (TEP) hernia repair after an original TEP Is it safe, and is it even possible? G. S. Ferzli, K. Shapiro, S. V. DeTurris, P. Sayad, S. Patel, A. Graham, G. Chaudry Surg Endosc (2004) 18: 526–528
      • Recurrence is generally approachable via the extraperitoneal route, although it often requires more care than primary repair.
      • Patients with new hernias contralateral to prior TEP repair can also be offered the preperitoneal approach.
    • Endoscopic extraperitoneal radical prostatectomy in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair . Jens-Uwe Stolzenburg Æ Chris Anderson Robert Rabenalt Æ Minh Do Æ Kossen Ho Michael C. Truss World J Urol (2005) DOI 10.1007/s00345-005-0001-y
      • Performing endoscopic extraperitoneal radical prostatectomy (EERPE) in patients with prostate cancer and previous TEP and TAPP was safe and feasible with a good operative outcome.
      • Modifications in the port placements were made to accommodate for previous mesh placements on the right and left side.
      • Lymph node dissection is not recommended on the side of the previous mesh placement.
    • IMPACT OF PREVIOUS SURGERY ON ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY JENS-UWE STOLZENBURG, KOSSEN M. T. HO, MINH DO, ROBERT RABENALT WOLFGANG DORSCHNER, AND MICHAEL C. TRUSS UROLOGY 65: 325–331, 2005. © 2005 Elsevier
      • Endoscopic extraperitoneal radical prostatectomy is feasible in patients with various previous abdominal surgical procedures (cholecystectomy, laparotomy, hemicolectomy,herniorraphy, TEP,TAPP ,appendectomy, abdominoperineal resection, sigmoid colectomy…).
    • IMPACT OF PREVIOUS SURGERY ON ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY JENS-UWE STOLZENBURG, KOSSEN M. T. HO, MINH DO, ROBERT RABENALT WOLFGANG DORSCHNER, AND MICHAEL C. TRUSS UROLOGY 65: 325–331, 2005. © 2005 Elsevier
      • Previous minimally invasive hernia repair with mesh placement made EERPE more demanding but was not a contraindication.
    • Totally extraperitoneal laparoscopic hernia repair in patients with previous lower abdominal surgery. Paterson H , Casey J , Nixon S . J Laparoendosc Adv Surg Tech A. 2005 Apr;15(2):121-4.
      • Retrospective review of 47 consecutive patients who underwent TEP inguinal hernia repair in the presence of lower abdominal scars between 1993 and 2002.
      • Thirty-five unilateral and 12 bilateral TEP hernia repairs were performed in the presence of 20 appendicectomy, 10 lower midline, 18 suprapubic and 5 paramedian incisions. Two cases were converted to open repair. There were no major complications and no early or late recurrences.
      • Totally extraperitoneal laparoscopic hernia repair can be carried out safely in the presence of scars from previous lower abdominal surgery.
    • Laparoscopic repair of recurrent hernias M. A. Memon,1 X. Feliu,2 E. F. Sallent,2 J. Camps,2 R. J. Fitzgibbons, Jr.3 Surg Endosc (1999) 13: 807–810
      • Although the actual recurrence rate of recurrent hernia is largely unknown, it is undoubtedly much higher than the rate for repair of primary hernia because of (a) distorted anatomy; (b) unsatisfactory and complicated repairs; and (c) repairs performed outside of specialist centers.
    • Laparoscopic repair of recurrent hernias M. A. Memon,1 X. Feliu,2 E. F. Sallent,2 J. Camps,2 R. J. Fitzgibbons, Jr.3 Surg Endosc (1999) 13: 807–810
      • The laparoscopic method, provides an ideal way of repairing the recurrent hernias because it is associated with better patient satisfaction and cost effectiveness by virtue of earlier hospital discharge, decreased recurrence rate, and reduction in sick leave and worker’s compensation that result in significant cost savings [12].
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • A number of publications have demonstrated the advantages of laparoscopic and endoscopic surgical techniques [7, 11, 17, 19, 20, 30, 31, 33, 37, 38], with some of these authors identifying TEP as the method of choice for recurrent hernias.
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • Treatment of recurrent hernia is substantially more complex than treatment of primary hernia. This is due to the high incidence of combined hernias, the need for a tension-free repair and closure of all potential hernia sites, the intrinsic and age-related connective tissue weakness, the difficult dissection due to scar tissue, and the frequently changed anatomical situation. The TEP procedure takes appropriate account of all these points.
      • The TEP technique enables an overview of all hernia sites, and by selecting an appropriately large patch (10 · 15 cm or larger if indicated) all potential hernia sites can be covered.
    • Preperitoneal repair for recurrent inguinal hernia: laparoscopic and open approach . Feliu X , Torres G , Vinas X , Martinez- Rodenas F , Fernandez- Sallent E , Pie J Ann R Coll Surg Engl. 2003 Nov;85(6):402-4.
      • Preperitoneal approach (open or laparoscopic) seems to be a good option in recurrent inguinal hernia when these procedures are done by experienced surgeons.
      • Postoperative complications were more frequent in the OPM group (23.9%) than the TEP group (13.9%) .
      • Hospital stay was significantly shorter in the TEP group (1.2 vs 3.9 days) .
    • A prospective comparison of ambulatory endoscopic totally extraperitoneal inguinal hernioplasty versus open mesh hernioplasty Hung Lau *, Nivritti G. Patil J. of Ambulatory Surgery 137 (2003) 137/141
      • TEP is a safe and efficacious technique for the repair of inguinal hernia in an ambulatory setting. It should be a therapeutic option for day case repair of inguinal hernia.
    •  
    • TEP conclusion
    • Totally extraperitoneal (TEP) hernia repair after an original TEP Is it safe, and is it even possible? G. S. Ferzli, K. Shapiro, S. V. DeTurris, P. Sayad, S. Patel, A. Graham, G. Chaudry Surg Endosc (2004) 18: 526–528
      • TEP repair of recurrent inguinal hernia after a primary TEP, as well as repair of contralateral hernia after earlier TEP repair, is technically feasible and safe.
      • Surgeons should attempt a TEP approach for a TEP recurrence or for contralateral repair only after significant experience with the primary TEP technique.
    • Endoscopic extraperitoneal radical prostatectomy in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair . Jens-Uwe Stolzenburg Æ Chris Anderson Robert Rabenalt Æ Minh Do Æ Kossen Ho Michael C. Truss World J Urol (2005) DOI 10.1007/s00345-005-0001-y
      • It is significant that the surgeon has requisite skills needed to overcome the difficulties created by the previous mesh placement.
    • Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy M. T. T. Knook,1 W. F. Weidema,2 L. P. S. Stassen,3 C. J. van Steensel2 Surg Endosc (1999) 13: 1145–1147
      • The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy.
    • Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies Maurice E. Arregui1  and Susan B. Young1 World Journal of Surgery Société Internationale de Chirurgie 2005 10.1007/s00268-005-7968-9
      • Although more difficult to learn and perform, laparoscopic hernia repair has the advantage of less pain and quicker recovery.
      • laparoscopic hernia repair can be done efficiently, safely, and with great success.
    • Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive pts H. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling Surg Endosc (2003) 17: 1072–1076
      • Although for its definitive management, recurrent hernia requires a reliable operative technique, current data do not support the recommendation of any of the currently available procedures as the gold standard.
      • In a representative patient population with recurrent hernia, we were able to demonstrate that TEP achieves very good results in terms of re-recurrence rate, intraoperative and postoperative complications, and rehabilitation.
      • Prerequisites for the reliable and low complication application of the method are a high level of standardization of the procedure and an advanced learning curve.
    • Totally extraperitoneal laparoscopic hernia repair in patients with previous lower abdominal surgery. Paterson H , Casey J , Nixon S . J Laparoendosc Adv Surg Tech A. 2005 Apr;15(2):121-4.
      • Totally extraperitoneal laparoscopic hernia repair can be carried out safely in the presence of scars from previous lower abdominal surgery.
    • Recurrent inguinal hernia: a ten-year review. Feliu X , Jaurrieta E , Vinas X , Macarulla E , Abad JM , Fernandez- Sallent E Hernia. 2005 May;9(2):120-4. Epub 2004 Oct 29
      • Laparoscopic repair is an effective option for the treatment of recurrent inguinal hernia.
      • The TEP approach combines the advantages of minimal invasive surgery and those of tension-free mesh repair, reducing operating time, postoperative morbidity, and recurrence rate.
    • Is Laparoscopic Inguinal Hernia Repair an Operation of the Past? Lorelei J Grunwaldt, MD, Steven D Schwaitzberg, MD, FACS, DavidW Rattner, MD, FACS, Daniel B Jones, MD, FACS American College of Surgeons Vol. 200, No. 4, April 2005
      • The VA Study confirmed the need for a high degree of technical expertise to avoid high recurrence and conversion rates.
      • Laparoscopic repair may not be a procedure for the average general surgeon unless one is committed to mastering technical expertise.
      • The repair is a technically challenging procedure with a steep learning curve.
    •