LAPAROSCOPIC HERNIA REPAIR- CONTEMPORARY DETAILS AND REVIEW OF LITERATURE

1. Current Status of Laparoscopy
Hernia Surgery
Dr Vipin V Nair
ASST PROF SURGERY
ACMS NEW DELHI

2. Definition
• An abnormal protrusion of the contents of a closed
cavity through a potential or an abnormal opening
with a containing sac

3. History of hernia repair is the History of surgery
Ancient Greeks differentiated between Hernia and Hydrocele

4. Causes of Hernia
Increased Intraabdominal pressure
Weakness of Abdominal wall

5. Increased Pressure
FAT
Putting on Weight
FLUID
Ascites
,BPH
FAECES & FLATUS
Severe
Constipation
FOETUS
Pregnency
FORCE
Smoking ,Asthma,
Heavy Weights

6. Weakness of Abdominal Wall
Age Operative Scar Muscle Bulk
Loss/Starvation

7. TYPES OF GROIN HERNIA REPAIR
• Tension Repair
– Bassini
– Shouldice
• Tension-free Repair
– Open
• Lichtenstein
• PHS
– Laparoscopic
• TAPP
• TEP

8. Lichtenstein's Tension Free Mesh Repair
1984 -ONLAY
Open anterior approach
Steps
Deal with the sac
Mesh sutured - floor and
around spermatic cord
Improved results
Simons MP, Bay-Nielsen M. European Hernia Society guidelines on the treatment of
inguinal hernia in adult patients. Hernia 2009 Aug;13(4):343-403. doi: 10.1007/s10029-
009-0529-7. Epub 2009 Jul 28.

9. TWO LAYER REPAIR
• 1998
• A secure posterior repair
from a simple anterior
approach
• Lowest reported
recurrence rates
Combined Anterior and Posterior Inguinal Hernia Repair: Intermediate recurrence
rates with three groups of surgeons Gilbert, AI et al. Hernia, 2004:8: 203-207

10. Laparoscopic Techniques
TAPP TEP

11. Laparoscopic Hernia Repair
• 1992
• Maurice Arregni
• TAPP
• 1993
• Berry MecKernan
• TEP

12. TAPP-Trans Abdominal Pre-Peritoneal
Transversalis
Fascia
Mesh
Incision
Preperitoneal Space Trocar

13. TAPP-Trans Abdominal Pre-Peritoneal

14. TAPP-Trans Abdominal Pre-Peritoneal

15. TEP-TOTAL EXTRA PERITONEAL REPAIR

16. TEP-Totally Extra-Peritoneal

18. Indications of lap repair
Recurrent hernia
• Avoids scar tissue
• Visualizes occult hernia
Bilateral hernia
• Decreased pain
• Earlier return to work
• No difference in recurrence or complication
Obese / Athletic patients
• Definitive diagnosis
• Reduced infection in susceptible population

19. Contraindications to lap hernia repair?
Contraindications
• Patients for whom general anesthesia and
pneumoperitoneum are risks (cardiac,
pulmonary disease)
Relative Contraindications
• Prior pre-peritoneal surgery
• (prostate, hernia, vascular, kidney transplant)
• Prior laparotomy
• Ascites
• Strangulated hernia
• Giant scrotal hernia
• Anticipated bleeding (patients on anti-
coagulation)

20. ADVANTAGES OF LAP SURGERY
• a

21. COMPARISION OF RECURRENCE RATES
0 1 2 3 4 5 6
BAY -NIELSON 01
EUHS 02
NEUMAYER 04
1.6
2.2
5.6
1.3
1.7
4.9
Chart Title
OPEN LAP

22. Recurrence rates for open and laparoscopic hernia repair
Reference Year Pts Hernia TechRR
Bay-Nielson 2001 547 Lap 1.6%
9,982 Licht 1.0%
4,373 Muscle repair 2.7%
EU Hernia 2002 1,643 Lap 2.2%
Trialist Collab 1,612 Open 1.7%
Neumayer 2004 862 Lap 5.6%
834 Open 4.9%
No difference in rate of recurrence between laparoscopic and open
procedures for primary hernia repair.

23. Recurrence in various hernia categories
0 1 2 3 4 5
Primary indirect
Primary direct
Primary bilateral
Recurrent
unilateral
0
1.1
4.8
4.6
1
3.1
3
4.8
OPEN
LAP
Wara et al (Dec BJS 2005)prospective analysis of consecutive lap and open repair (w.e.f.
1998- 2003)

24. Recurrence in various hernia
categories
Lichtenstein (n=39537) LAP (n=3606)
• primary indirect: 1.0 % 0 %
• primary direct: 3.1 % 1.1%
• primary bilateral: 3.0 % 4.8 %
• recurrent unilateral: 4.8 % 4.6 %
• recurrent bilateral: 7.6 % 2.6 %
Wara et al (Dec BJS 2005)prospective analysis of consecutive lap and open repair (w.e.f.
1998- 2003)

25. Chronic Groin pain after 2 mts - VAS
0 2 4 6 8 10
MAHON 03
DEDEMADI 06
EKLUND 07
KOUHIA 09
2.8
1
2.1
4
4.3
2
3.8
9
OPEN
LAP

26. Post Operative Chronic Pain
Reference Year Technique No. of Patients Median VAS
Mahon 2003 TAPP/Licht. 60/60 2.8/4.3 (p = 0.003)
Dedemadi 2006 TAPP/Licht. 24/32 1.0/2.0 (p = 0.001)
Eklund 2007 TAPP/Licht. 73/74 2.1/3.8(p = 0.001 )
TEP/Licht 675/706
Bringman 2003 TEP/Licht 92/103 2.8/4.8 (p = 0.001)
Kouhia 2009 TEP/Licht 47/49 4/9 (p = 0.02)
VAS, visual analog of pain score; TAPP, trans-abdominal pre-peritoneal repair; GPRVS, giant prosthesis for reinforcement of visceral sac; Licht.,
Lichtenstein repair; Lap, laparoscopy

27. Return to Normal Activities
0 5 10 15 20 25
Bringman 2003
Eklund 2007
Kauhia 2009
Dademadi 2006
14
7
12
14
25
12
18
20
OPEN
LAP
days

28. Return to regular activity after TEP inguinal hernia repair
Reference Year Technique Median days to return to work / activity
Bringman 2003 TEP/Licht/Mesh-plug 14/25/29 (p < 0.0001)
Eklund 2007 TEP/Licht 7/12 (p <0.001)
Kouhia 2009 TEP/Licht 15/18 (p = 0.05)
TEP, totally extra-peritoneal repair; Licht., Lichtenstein repair

29. Return to regular activity after TAPP for recurrent inguinal
hernia
Reference Year Technique
Median days to return to work /activity
Beets 1999 TAPP/GPRVS 13/23 (p = 0.03)
Neumayer 2004 Lap./Licht. 4/5 (adj. HR 1.2; 95% CI 1.1 - 1.3)
Eklund 2007 TAPP/Licht 8/16 (p = 0.001)
Dedemadi 2006 TAPP/Licht 14/20 (p = 0.001)
TAPP, trans-abdominal pre-peritoneal repair; GPRVS, giant prosthesis for
reinforcement of visceral sac;
Licht., Lichtenstein repair; HR, hazard ratio; CI, confidence interval; Lap,
laparoscopy

30. Cost Analysis
• MRC trial group
– extra cost 323.85 pound
• Wellwood et al
– additional expense of
334.60 pound
• Unilateral hernia open
method is cost
effective.
0 500 1000
MRC
GROUP
WELLWOOD
633.85
658.6
310
325
OPEN
LAP
•Medical Research Council Laparoscopic Groin Hernia Trial Group (2001) Cost–utility analysis of open versus
laparoscopic groin hernia repair: results from a multicentre randomized clinical trial. Br J Surg, 88, 653–61.
•Wellwood J, Sculpher MJ, Stoker D et al. (1998) Randomised controlled trial of laparoscopic versus open mesh
repair for inguinal hernia: outcome and cost. BMJ, 317, 103–10.

31. Laparoscopic hernia repair is better.
• Considering cost utility analysis and
• Quality of life
• Bilateral hernias
• Women

32. Femoral hernia
• 3,980 femoral hernia repairs
from Swedish Hernia
Register
• 1,490 men, 2,490 women
• Women at higher risk
than men
Women
63%
Men
37%
Sales
Dahlstrand UD, Wollert S, Nordin P, Sandblom G, Gunnarsson U. Emergency femoral
hernia repair A Study based on a national register. Ann Surg 2009; 249: 672-676.

33. Femoral hernia
Bisgaard 2008 Repair type Femoral recur. Re-recurrence
Rate
n = 2,117 re-operations Endoscopic rep. n = 34 0.00%
Open repair n = 161 8.07%
EHS 2010 Endo n 16 o.oo%
N 1185 Open repair n = 88 7.47%
TAPP allows full visualization of the floor and avoids
missed concomitant ipsilateral or contralateral
hernias

34. Recurrence In Femoral Hernia
0 2 4 6 8 10
BISGARRD 08
EHS 10
0
0
8.07
7.47
OPEN
LAP

35. Problems of lap hernia repair
Visceral injuries
Great vessel injuries
Urinary injuries

36. RECOMMENDATIONS FOR GROIN
HERNIA REPAIR

37. NICE 2009 guidelines
• Laparoscopic surgery -one of the
treatment options
• Between open and laparoscopic
surgery the following are
considered:
• Nature of the presenting
hernia
• Suitability for a laparoscopic
or open approach
• Trained lap surgeon

38. European Hernia Society guidelines
2009
Endoscopic surgery Recommended
for
Female Groin hernia
Bilateral Hernia
• Lap-lower incidence
– Wound infection
– Haematoma formation
– Earlier return to normal
activities or work
– Postoperative pain .
Simons MP, Bay-Nielsen M. European Hernia Society guidelines on the treatment of inguinal
hernia in adult patients. Hernia 2009 Aug;13(4):343-403. doi: 10.1007/s10029-009-0529-7.
Epub 2009 Jul 28.

39. European Hernia Society guidelines
2009
• Primary unilateral hernias
– open repair
• Bilateral hernias.
– Endoscopic procedure
– cost-effective
• In cost–utility analyses
including quality of life
(QALYs), endoscopic
techniques (TEP) is
preferable

40. Cochrane Summaries
McCormack K, Scott N, Go PM.N.Y.H, Ross SJ, Grant A, Collaboration the EU Hernia Trialists
Published Online Laparoscopic techniques versus open techniques for repair of a hernia in
the groin : October 8, 2008
Laparoscopic repair
•Return to usual activities --- faster by 7 days
•Less persisting pain and numbness
• Operation times -15 minutes longer
•Higher number of serious complications
•visceral (especially bladder)
• vascular injuries.

41. Two different laparoscopic techniques for repairing a hernia in the groin Wake BL, McCormack K,
Fraser C, Vale L, Perez J, Grant A, October 8, 2008
Cochrane Summaries
No statistical difference between TAPP and TEP when
considering
Duration of operation
Hematoma
Length of stay
Time to return to usual activity
Recurrence.

42. TAPP associated with
Higher rates of port-site hernias
Visceral injuries
Vascular injuries
Deep/mesh infections
Cochrane Summaries
Two different laparoscopic techniques for repairing a hernia in the groin Wake BL, McCormack K,
Fraser C, Vale L, Perez J, Grant A, October 8, 2008

43. Female Patients
• Higher risk – recurrence
(inguinal or femoral)
• Existence of a femoral hernia
excluded in all cases of a hernia in
the groin.
• TEP(endoscopic)
• ideal in female hernia repair.
European Hernia Society Guidelines: Treatment of Inguinal Hernia in Adult
Patients.2010

44. • TAPP Required
• TEP NOT recommended
– Increased operative cost
– Chronic pain
– No difference in recurrence
Laparoscopic inguinal hernia repair without mesh fixation, early results of a large
randomized clinical trial Surgical Endoscope volume 22, Number 3 / March, 2008 Arch Surg. 2010
Apr;145(4):334-8.
Total extraperitoneal laparoscopic inguinal hernia repair without mesh fixation: prospective study with 1-year
follow-up results.
Mesh fixation

45. Conclusion
• Laparoscopic inguinal hernia repair CHOICE for
– Bilateral
– Femoral
– Recurrent hernias post open surgery
• Considered as alternative for
– Unilateral groin hernia
• Main challenge
– Learning curve.