Laparoscopic Hernia Repair

In light of the huge benefit gained by the laparoscopic approach to cholecystectomy -- and the rapid acceptance of that technique by most surgeons -- much interest was given to the concept of laparoscopic hernioplasty, which was introduced widely around 1990. However, many surgeons who explored this approach to hernia repair found the learning process to be longer and more challenging than that seen for laparoscopic cholecystectomy or open herniorrhaphy.^[46-48] For this and other reasons, the optimal and most appropriate use of the laparoscopic technique remains a subject of debate among general surgeons.^[49]

Laparoscopic herniorrhaphy requires general rather than local anesthesia, takes more time, costs more,^[50,51] and carries the potential for more significant surgical complications than those encountered with open techniques.^[48] As a result, at least one large trial has concluded that laparoscopy should remain the province of specialists, with open procedures the approach of choice for most general surgeons,^[47] although it is unclear exactly what proportion of hernia repairs are performed laparoscopically, most current estimates are around 15%. Still, proponents note, this approach adheres to the concept of the tension-free repair and has excellent long-term results with minimal risks when employed by those surgeons skilled in advanced laparoscopic techniques.

Of interest, though not well known, is the fact that the laparoscopic approach to hernia repair actually predated the laparoscopic cholecystectomy. In 1982, Ger reported the repair of inguinal hernias in 13 patients with a stapling device; the 13th patient in this series underwent a laparoscopic repair, the earliest recorded attempt utilizing this technique.^[52] This patient, who underwent the procedure in 1979, was free of recurrence at the time of the report. Later, Ger and colleagues reported the use of a "herniostat," a prototypical stapling device to close the neck of the hernia sac in beagle dogs.^[53]

Bogojavalensky initially presented the use of a prosthetic biomaterial in this repair in 1989.^[54] He placed a roll of polypropylene mesh into indirect hernias of female patients, followed by a closure of the back of the hernia sac with sutures. This repair received little attention but was revisited by Shultz.^[55] Preliminary results from these repairs were promising, but later follow-up of these patients revealed that a recurrence rate of 16%-20% could be expected.^[56] This incidence of failure of this repair resulted in its abandonment.

Various techniques have been devised for laparoscopic herniorrhaphy. Initially, the approach involved a simple ring closure, but this technique failed because the deeper aponeurotic tissues could not be approximated without tension in the repair.^[40] The plug-and-patch technique also failed to match the results of its open counterpart.^[41,42] This was followed by the development of the intraperitoneal onlay mesh technique (IPOM).^[57,58] (Figure 41)

Figure 41. Intraperitoneal polypropylene or expanded Gore-Tex patch stapled to the anterior abdominal wall.

The IPOM technique focused on the placement of an intra-abdominal piece of a prosthetic biomaterial (usually a polypropylene or expanded polytetrafluoroethylene fixed with some type of stapling device); the repair did not involve the dissection of the peritoneum. The advantages of this repair were the lack of significant dissection of the preperitoneal space and the rapid placement of the prosthesis. The recurrence rate, however, was somewhat higher that that of the more widely adopted repairs developed later.^[59]

The IPOM was largely rejected because of the potential for the mesh anchored to the peritoneum to slip into the hernia defect, resulting in bowel adhesions and/or intestinal obstruction.^[43-45] It was believed that proper fixation of the biomaterial could only be insured by its placement in direct contact with the fascia of the transversalis muscle. This led to the development of the transabdominal preperitoneal (TAPP) repair method. (Figure 42). In this approach, the preperitoneal tissue is removed from the fascial layer by directly entering the intra-abdominal cavity. This is similar to the IPOM approach, except that TAPP involves more dissection of the preperitoneal space. With TAPP, which became very popular among laparoscopists, the prosthesis is placed into the preperitoneal space following dissection, fixed with a stapling device or a spiral tacking device, and covered.^[60] The preperitoneal tissue is secured into its original position at the completion of the procedure. The first reported use of the TAPP approach was by Schultz,^[55] who, in an initial series, used a portion of polypropylene mesh placed over the defect to cover the myopectineal orifice. The surgeon closed the peritoneum with clips to cover the prosthetic biomaterial.

Figure 42. Polypropylene patch sutured over the groin defects through a transperitoneal approach.

Some surgeons believed that the dissection required by the TAPP method could be accomplished without entry into the abdominal cavity.^[61] This seemingly would minimize the potential for injury to the intra-abdominal organs while eliminating the exposure of the bowel to the prosthetic biomaterial. This repair, the totally extraperitoneal approach (TEP), has been increasingly favored among experienced laparoscopists^[46] (Figure 43) and appears to be the most commonly used laparoscopic repair today.^[62] Experience also has shown that use of a larger prosthesis decreases the recurrence rate.^[63]

Figure 43. Extraperitoneal placement of mesh without entering the peritoneal cavity.

The TEP approach generally employs a preperitoneal dissection balloon that is introduced via a subumbilical incision. The balloon is inflated, creating the preperitoneal space for the hernia repair. Once this is completed, the laparoscope is inserted to visualize the working area. Two or 3 additional working ports are then placed to complete the necessary surgical dissection in which to adequately expose the inguinal floor and the myopectineal orifice.

Once the hernia defects are visualized, a polypropylene or expanded polytetrafluoroethylene biomaterial is then inserted and secured to the transversalis fascia and/or Cooper's ligament with tacks or staples. The material is of a size that completely covers the myopectineal orifice. This represents an advantage of the laparoscopic technique over anterior mesh or plug alone, in that it will cover all areas that are at risk of inguinal or femoral herniation. The results of this method have compared favorably with the open tension-free repair.^[64] The reported recurrence rate in over 10,000 hernia repairs was 0.4%.

There is continuing and vigorous debate over the relative clinical and economic pluses and minuses of laparoscopic and open hernia repair techniques. Several dozen studies in the past 2 years alone have not settled this controversy.^[65,66] There is general agreement that the costs of the laparoscopic approach are greater than those associated with open procedures,^[50,51] although some studies have found those higher costs can be reduced significantly with experience.^[67] Controlled trials and case series reported in the literature to date have reached variable conclusions when comparing clinical outcomes; a number found laparoscopy superior to open repairs in certain patients in terms of morbidity, patient satisfaction, return to work, and return to normal activity.^[48,68,69] Some found overall clinical results comparable.^[70-72] A number of others found open repairs equal or superior to laparoscopy when a variety of outcome measures were taken into account.^{[48,49,73,74]}

Ongoing trials, including one large series still under way, may bring more clarity to this debate. Many consider this to be an ideal repair of the hernia recurrence or for the repair of bilateral inguinal hernias. Others deem the risks and costs of this procedure to be too great to justify its use for any patient. Open repair remains the clear choice of the majority of general surgeons who perform this procedure. But proponents of the laparoscopic approach note that this procedure will find its place within the surgical armamentarium and, as with most general surgical operations, will be most appropriately used by those clinicians with the technical skills necessary to perform it optimally.