Management of Recurrent Inguinal Hernias:Laparoscopic Repair (TAPP)

George S Ferzli, MD, FACSMichael Timoney, MDAnne Erickson, CMI

SUNY Downstate Medical CenterLutheran Medical CenterBrooklyn, New York

AMERICAN COLLEGE OF SURGEONS94TH ANNUAL CLINICAL CONGRESS OCTOBER 2008

Nothing to disclose.

The following slides are intended

for mature audiences only.

Any similarity to actual events or real people

is purely coincidental.

There is a “Bond” inside each surgeon,

as there is a surgeon inside “Bond”.

“The Man with the Golden Mesh”???

Driving on the New Jersey Turnpike, Bond couldn’t help notice the billboard: hernia repair?

These claims about TAPP for recurrence need to be investigated – I’d better contact Moneypenny…

…Recurrence rates low? Post-op pain? Early return to work? No missed hernias?

“Q”

James, this issue is Very Big – I’ve recalled all the 007s for this case and am handing you over to“Q”.

He will help you with this investigation.

“K” “S” “D”

Hello James – let me introduce you to the rest the team who’ve been working around the clock on this.

First, what % of a general surgeon’s practice do you think are recurrent hernias? You’d be surprised–did

you know:

• Repair of recurrent hernia is a surrogate for actual recurrence rate.

• The reoperation rate is not equal to the true recurrence rate but is a measure of recurrence serious enough to require reoperation.

• The actual incidence of recurrence is higher than stated reoperation rates by at least 50%.

% Hernia Repairs that Present Overall in Population-based Studies and Large Case Series

Nilsson 1998 (Denmark) 16%

Felix 1998 (USA) 14%

Liebl 1999 (Germany) 8.5%

Haapaniemi 2001 (Sweden) 15%

Bay-Nielson 2001 (Denmark) 17%

Bokeler 2007 (Germany) 14%

Bisgaard 2008 (Denmark) 3.1%

Consider also, that you have to be good at repairing recurrent inguinal hernias…

• Bisgaard 2008 Danish Hernia Database ( 67,306 primary repairs)

– Recurrence rate of primary inguinal hernia repair – 3.1%

– Recurrence rate after recurrent inguinal hernia repair – 8.8%

• Other studies demonstrate re-recurrence rates as high as 33%

• Indeed, specialty centers show low recurrence rates for their techniques.

• Open tension free repair 0% – 8.30%

• Laparoscopic TAPP repair 0% – 1.04%

Is there Truth or “Truthiness” to this claim of

Fewer Re-recurrences?

has compiled these chronological files for you:

Our Intelligence Unit

Study Primary Repair Recur. Repair Tech. Re-recurrence Follow up

• Sandbilcher 1996 Anterior (muscle) TAPP 0.5% 18 monthsProspective

Single institutionn = 192 patientsn = 200 recurrent herniasLaparoscopic repair can be applied to recurrent hernia with low morbidity and recurrence.

• Felix 1996 Anterior (not sp.) TAPP (n = 124) 0.58% 2 yearsReview TEP (n = 49)Single institutionn = 152 patients n = 173 recurrent herniasLaparoscopy helps eliminate early failure resulting from missed hernia and intrinsic weakness.

• Jarhult 1999 Anterior (not sp.) TAPP (n = 113) 11% 49 months

Review TEP (n = 168) 2%Single institutionn = 260 patientsn = 281 recurrent hernias

After a learning curve, laparoscopic repair of recurrent hernia can be performed with low recurrence. TEP is preferable. TAPP used primarily during early period. Later, TEP used primarily.Recurrence rate decreased from 23% (1st year) 8% (2nd year) 1% (3rd year) 4% (4th year)

Recurrence after TAPP for Prior Hernia Repair Recurrence

Study Primary Repair Recur. Repair Tech. Re-recurrence Follow up

• Beets 1999 Anterior (not sp.) TAPP (n = 56) 12.5% 34 months Randomized controlled trial GPRVS (n = 52) 1.9%n = 79 patientsn = 93 recurrent herniasn = 15 concomitant primary herniasLaparoscopic recurrent hernia repair has lower morbidity vs. GPRVS but is difficult and has higher recurrence rate.

• Memon 1999 Anterior (not sp.) Laparosopic 27 monthsReview TAPP (n = 68) 2.94 %Three institutions TEP (n = 8) 0n = 85 patients IPOM (n = 19 ) 10.53%n = 96 recurrent hernias Unknown (n = 1) 0Laparoscopic recurrent hernia repair is safe, with acceptable recurrence and complication rates.

• Haapaniemi 2001 Anterior (not sp.) Lap. (TAPP and TEP) 1.79% (0.4) 2 yearsReview of prospective (n = 670)Swedish hernia registry Lichtenstein (n = 685) 1.46% (0.4)n = patient total not provided Plug (n = 276) 2.54% (0.9)n = 2,688 recurrent hernias Other Mesh (n = 574) 3.83% (0.9) Non-mesh (n = 483) 4.35% (1.0)Study supports use of laparoscopy or anterior tension-free repair of recurrent hernia.

Recurrence after TAPP for Prior Hernia Repair Recurrence

Study Primary Repair Recur. Repair Techn. Re-recurrence Follow up

• Bay-Nielson 2001 Various TAPP (n = 560) 2.9% NAReview of prospective TEP (n = 78) 1.3%Danish Hernia Registry Muscle repair (n = 645) 6.7%n = patient total not provided Lichtenstein (n = 1,697) 3.2%n = 3,943 recurrent hernias Plug (n = 212) 3.8% Plug and patch (n = 358) 3.6% Other mesh (n = 393) 5.6%Mesh repairs have lower reoperation rates than conventional open repair.

• Hawasli 2002 Anterior (not sp.) TAPP (screen and plug) 0.7% 5 yearsReviewSingle institutionn = 120 patientsn = 135 recurrent herniasRecurrent hernia rate is high. These patients have a tendency toward contralateral hernia. Most recurrences occur after 10 years. TAPP is a good repair for recurrent inguinal hernia

• Keider 2002 Anterior TAPP (n = 115), 5.7% 37 monthsReview TEP (n = 15)Single institutionn = 130 patientsn = 150 recurrent herniaLaparoscopic recurrent hernia repair is effective and superior to historical series – it should be the method of choice if cost could be reduced.

Recurrence after TAPP for Prior Hernia Repair Recurrence

Study Primary Repair Recurrent Repair Technique Re-recurrence Follow up

• Mahon 2003 Anterior (not sp.) TAPP (n = 60) 6.67% 3 monthsRandomized Lichtenstein (n = 60) 1.67%ProspectiveSingle institutionn = 120 patients n = 42 recurrent, 71 bilateral and 7 both bilateral and recurrent herniasTAPP is beneficial, in terms of pain and return to work, for patients undergoing bilateral or recurrent hernia repair.

• Neumayer 2004 Anterior (not sp) Laparoscopic (10% TAPP) (n = 81) 10.0% 2 yearsRandomized Lichtenstein (n = 78) 14.1% Prospective Multi-center n = 1,983 patients Experienced Laparoscopy (n >250) 3.6% n = 1,983 total hernias (n = 28)n = 159 recurrent hernias Experienced Lichtenstein (n >250) 17.2%

(n = 64)Open mesh repair is superior to laparoscopy for primary hernia repair, but recurrence rates are similar for recurrent hernia repair and for surgeons who are highly experienced.

Recurrence after TAPP for Prior Hernia Repair Recurrence

Study Primary Repair Recur. Repair Techn. Re-recurrence Follow up

• Wara 2005 Lichtenstein Unilateral recurrent hernia Review of prospective TAPP (91.7%); TEP (8.3%) 4·63% NADanish hernia registry (n = 1,361)n = patient total not provided Lichtenstein 4·79%n = 6,689 recurrent hernias (n =4,633)

Lichtenstein Bilateral recurrent hernia TAPP (91.7%); TEP (8.3%) 2·61% (n = 498)

Lichtenstein 7·56% (n = 172)

Mixed Licht. and Lap. TAPP (91.7%); TEP (8.3%) 0% (n = 6)

Lichtenstein 0% (n = 19)

Laparoscopic repair is comparable to Lichtenstein for primary hernia and unilateral and bilateral recurrent hernia, but inferior for primary bilateral hernia.

Recurrence after TAPP for Prior Hernia Repair Recurrence

Study Primary Repair Recur. Repair Techn. Re-recurrence Follow up

• Dedemadi 2006 Anterior (not sp.) TAPP (n = 24) 8.33% 3 yearsProspective TEP (n = 26) 7.69%Randomized Lichtenstein (n = 32) 15.63%n = 82 patientsn = 82 recurrent herniasLaparoscopic hernia repair is the method of choice for recurrent inguinal hernia.

• Eklund 2007 Anterior (not sp.) TAPP (n = 73) 16.44% 5 yearsProspective Lichtenstein (n = 74) 16.23%RandomizedMulti-centern = 147 patients n = 147 recurrent herniasLaparoscopic hernia repair has the short term advantage of less post-op pain and shorter sick leave.

• Bokeler 2008 Anterior (not sp.) TAPP 0.60% NARetrospectiveSingle institutionn = 1,689 patientsn = 1,755 recurrent herniasLaparoscopic hernia repair should be the “Gold standard” in the treatment of recurrent hernias after anterior repair, but it is essential to gain experience by using the laparoscopic technique for primary hernias.

Recurrence after TAPP for Prior Hernia Repair Recurrence

Study Primary Repair Recurrent Repair Technique Re-recurrence Follow up • Bisgaard 2008 Lichtenstein TAPP (approx. 95%) (n = 388) 1.3% NA

Review of prospective Lichtenstein (n = 344) 11.3%Danish hernia registry Nonmesh (n = 198) 19.2%n = patient total not provided Mesh (non-Lichtenstein) (n = 194) 7.2%n = 1,124 recurrent herniasLaparoscopic repair is recommended for reoperation of recurrence after primary open Lichtenstein repair. Trend favors laparoscopic repair of recurrence after non-mesh and non-Lichtenstein mesh primary repair. Laparoscopic repair of recurrence after laparoscopic primary repair shows no advantage in terms of re-recurrence.

• Tantia 2008 Anterior (not sp.) TAPP (n = 37), TEP (n = 28) 0.65% 36 months

ProspectiveSingle institutionn = 61 patientsn = 65 recurrent herniasLaparoscopic repair of recurrent inguinal hernia is safe and effective with low morbidity and recurrence and should be the gold standard for these hernias.

Recurrence after TAPP for Prior Hernia Repair Recurrence

James.

Let’s scrutinize the data to see if there is any support for the surgeon’s second claim:

Less Post-op pain.

TAPP for Recurrent Hernia: Post-operative pain

Study Repair Technique Median Visual Analog of Pain Score (VAS)

• Beets 1999

1 week after surgery TAPP (n= 42) 2.2 p = 0.005 GPRVS (n = 37) 2.9

• Mahon 2003 Median VAS24 hours after surgery TAPP (n = 60) 2.8 p = 0.003 Lichtenstein (n = 60) 4.3

• Neumayer 2004 Difference in VASPain at day of surgery 10.2 mm (favoring TAPP)Pain at two weeks after surgery 6.1mm (favoring TAPP)Pain at 3 month after surgery No difference

TAPP for Recurrent Hernia: Post-operative pain

Study Repair Technique Median VAS

• Dedemadi 2006

Day of Surgery TAPP (n = 24) 4 p = 0.004 Lichtenstein (n = 32) 5

24 hrs after surgery TAPP 1 p = 0.001 Lichtenstein 4

7 days after surgery TAPP 1 p = 0.001 Lichtenstein 2

Analgesia use Mean analgesia useTAPP 1.9 days p = 0.004Lichtenstein 3.2 days

• Eklund 2007 Median VASPain at 1 week after surgery TAPP (n = 73) 125 mm p = 0.019

Lichtenstein (n =74) 165 mm p = 0.001 • Median analgesia consumption decreased with TAPP vs Lichtenstein• The short term advantage for patients who undergo laparoscopic repair is less postoperative pain.

OK: let’s consider his third claim:

Earlier return to work or activity

Here are the figures concerning return to work and activity

Study Median Return to Work / Daily Activities

• Beets 1999 TAPP 13 days (p= 0.03) GPRVS 23 days

• Mahon 2003 TAPP 11 days (p = < 0.001) Lichtenstein 42 days

• Neumayer 2004 Laparoscopy 4 days (adjusted hazard ratio 1.2; 95% CI, 1.1-1.3) Lichtenstein 5 days

• Dedemadi 2006 TAPP 14 days (p = 0.001) Lichtenstein 20 days

• Eklund 2007 TAPP 8 days (p=0.001) Lichtenstein 16 days

Trend increased with increased occupational exertion (p = 0.001)The short term advantage for patients who undergo laparoscopic repair is shorter sick leave.

4th claim-no missed hernia

• Crawford found an incidence of 8% occult femoral hernia at laparoscopic repair, and Felix found 9% concurrent femoral hernia.

• Felix 1996 Recurrent Primaryn = 152 patients Femoral 9% 4%n = 173 recurrent hernias Pantaloon 25% 14%

• Chan’s series of 225 repairs of femoral hernia repairs demonstrated 50.9% had concurrent inguinal hernia

– 5.8% had bilateral femoral hernia and 18.2% had prior groin hernia repair.

Chan believes prior inguinal hernia repair may precipitate a femoral hernia (15 x higher according to Mikkelsen etal).

• Bisgaard 2008 Repair Type Femoral Recurrence Re-recurrence Raten = 2,117 re-operations Endoscopic repair n = 34 0.00% Open repair n = 161 8.07%TAPP allows full visualization of the floor and avoids missed concomitant ipsilateral or contralateral hernias.

No missed hernia?

Well, what about TAPP after TAPP?

Hello.

The name is TAPP…

James TAPP.

Study Primary Repair Recur. Repair Techn. Re-recurrence Follow up• Knook 1999 Various Laparoscopic TAPP 0.0% 35 months

Review (n = 34)Three institutionsn = 34 patientsn = 34 recurrent herniasTAPP is a reliable technique for repair of recurrent hernia prior endoscopic repair.

• Liebl 2000 TAPP (n =44) TAPP 0.0% 26 monthsReview of TEP (n = 2)ProspectiveSingle institution seriesn = 44 patientsn = 46 recurrent hernias

Laparoscopic repair of recurrent inguinal hernia after TAPP can only be done by the transperitoneal approach. It is effective with low complication rates. It requires large mesh. For reoperation, it should be reserved for the experienced endoscopic surgeon.

• Kapiris 2001 TAPP (n=17) TAPP (n=16) 0.62% (all repairs) 45 monthsRetrospectiveTwo institutionsn = 3,017 patientsn = 3,530 total hernias n = 388 recurrent hernias TAPP is difficult but safe and effective, with high patient satisfaction, in the hands of the well trained surgeon.

TAPP after Recurrence of TAPP Hernia Repair

Study Primary Repair Recur. Repair Tech. Re-recurrence Follow up

• Keider 2002 TAPP / TEP TAPP / TEP 0.0% 37 monthsReview (n = 3)Single institutionn = 3 re-operations by laparoscopy after 7 re-recurrences after laparoscopyLaparoscopic recurrent hernia repair is effective and superior to historical series. It should be the method of choice if cost could be reduced.

• Bittner 2007 TAPP TAPP 0.74% NAReview (n = 135)Single institutionn = 135 recurrent herniasTAPP can be performed for recurrent inguinal hernia after TAPP with low recurrence rate, but the learning curve is high.

• Bisgaard 2008 Laparoscopic TAPP (approx. 95%) (n = 14) 7.1% NAReview of prospective (n = 100) Lichtenstein (n = 73) 2.7%Danish hernia registryNonmesh (n = 8) 0.0%n = 67,306 primary repairs Mesh (non-Lichtenstein) (n = 5) 0.0%n = 100 recurrent hernias after lap. Laparoscopic repair is recommended for reoperation of a recurrence after primary Lichtenstein repair. Trend favors laparoscopic repair of recurrence after non-mesh and non-Lichtenstein mesh primary repair. Laparoscopic repair of recurrence after laparoscopic primary repair shows no advantage in terms of re-recurrence.

TAPP after Recurrence of TAPP Hernia Repair

TAPP after präperit.mesh-rep.

n = 135*

op-time [median,min.] 75

morbidity 8,1 %

reop.-rate 2,2 %

rec.-rate 0,74 %

return to work [med,d] 17

age [median] 59 [29-90]

BMI [median] 25

Marienhospital Stuttgart IV / 93 – XII / 05 resultsresults

Laparoscopic Hernia Repair (TAPP)

*own recurrences n=73 from outside n=62

But Dr. TAPP, what about complications?

…unless you “goldplate” your patient, there are going to be complications.

James:

• Eight non-randomized studies suggest that TAPP is associated with higher rates of

port-site hernias and visceral injuries whilst there appear to be more conversions

with TEP.

• Edwards demonstrated decreased complications and recurrence after 30 TAPP

procedures.

• Neumayer found that the surgeon only became proficient enough at laparoscopic

hernia repair to have improved recurrence rates vs anterior repair after over 250

procedures

Complications (From Bokeler)

* RCT (in parentheses data of TAPP)

Recurrent inguinal hernia and open re-surgery

Zuvela 2003

Mahon 2003

Feliu 2004

Isemer 2004

Farooq 2005

Beltran 2006

Alani 2006

Eklund 2007*

Hematoma Infection Orchitis

2.1%

3,3% (6,8 %)

8.2%

3.7%

1.5%

11%

14.8%

22% (7%)

TesticularAtrophy

-

13,3% (3,4%)

1.6%

0.2%

3%

?

-

3% (1%)

2.1%

1,7% (0%)

1.6%

?

-

?

-

4% (0%)

-

1,7 % (0%)

-

0.2%

-

?

-

3% (0%)

n (Prof)* 1-45(1-20)* 46-90(21-40)* 91-135(41-56)*

(6/93-12/98) (12/98-02/02) (2/02-11/05)

op-time [median,min.](Prof.)* 82,5 (87,5)* 71 (85)* 77 (57,5)*

morbidity 14% 8 % 2%

reop.-rate 2,2% 2,2% 2,2 %

rec.-rate - - 2,2 %

return to work[med.,d] 18 17 17

ResultsResults (n=135) (n=135)[“learning curve”][“learning curve”]

TAPP after preperitoneal mesh repair

Marienhospital Stuttgart IV / 93 – XII / 05

results results [Marienhospital Stuttgart Apr’ 93 – Dez’ 07]

*eigene Rezidive: n=92 extern vorop: n=70

PH (without preop.)

last 2000

40

1,7%

0,3%

0,1%

10

50 [17-100]

25

PH

n=13136

40

2,8%

0,4%

0,7%

14

60 [17-97]

25

scrotal hernia

n=807

60

4,4%

0,85%

2,3%

17

61(18-97)

25

post. repair

n=162*

75

7,0%

3,8%

0,6%

17

59 [29-90]

25

n

op-time [med.,min.]

morbidity

reop.-rate

rec.-rate out of work [med.,days

age [Median]

BMI [Median]

TAPP Marienhospital Stuttgart, 3 / 1993 – 12 / 2007

Recurrence after anterior and posterior repairs

• Laparoscopic posterior repair after posterior repair does not have the benefit of operating in virgin territory and may be best left to those surgeons with extensive laparoscopic experience.

Should the prior mesh be removed or left in place?

• Sometimes the old mesh is difficult to remove and bowel and bladder injuries could occur (or the old plug just can’t be cut with scissors). “We left the prior mesh in situ. The dissection starts from the upper edge down behind the mesh, so the mesh remains at the peritoneum. It prevents damage to the peritoneum. Depending on the intra-operative situation we use a second mesh with or without a slit in a double-buttress technique”

– Jochen Schwarz, personal correspondence

Dr. TAPP– are there anymore pitfalls of TAPP for repair of recurrent hernia?

Well Moneypenny, I guess that wraps things up here.

Yes James… use of TAPP for recurrent inguinal hernias is mere child’s play compared with what’s ahead… “Q” will be in touch.

What’s this – Bill Fritz, a doctor, advertising for Coke…

I thought he was taking care of my malpractice insurance!

Back on the Turnpike…

Well, it looks like Dr. TAPP’s claims might be OK…

if an expert beyond the learning curve is operating.

Think I’ll just catch the new James Bond movie “Quantum of Solace”.

November 2008

The End.

References

• Bisgaard T, et al. Re-recurrence after operation for recurrent inguinal hernia. A nationwide 8-year follow-up study on the role of type of repair. Ann Surg, 2008, 247(4):707-711

• Nilsson E, et al. Methods of repair and risk for reoperation in Swedish hernia surgery from 1992 to 1996. Brit J Surg 1998, 85: 1686–1691

• Felix EL, et al. Laparoscopic repair of recurrent groin hernias. Surg Laparosc Endosc 1994, 4: 200-204

• Liebl B, et al. Recurrence after endoscopic transperitoneal hernia repair (TAPP): Causes, reparative techniques, and results of the reoperation. J Am Coll Surg 2000 190(6): 651-655

• Haapaniemi S, et al. Reoperation After Recurrent Groin Hernia Repair Ann Surg 2001, 234(1): 122–126

• Bay-Nielsen M, et al. Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 2001; 358: 1124–1128

• Bökeler U, et al. TAPP: An ideal technique for the treatment of recurrent hernia after open repair. AHS, Scottsdale 2008

• Schaap HM et al. The preperitoneal approach in the repair of recurrent inguinal hernias. Surgery, Gynecology & Obstetrics 1992 Jun;174(6):460-4

• Bendavid R. Expectations of hernia surgery (inguinal and femoral). In: Paterson-Brown S, Garden J (ed) Principals and practice of surgical laparoscopy. WB Saunders, 1994 Philadelphia pp 387-414

References

• Schultz C, et al. Laparoscopic inguinal hernia repair. Surg Endosc 2001, 15: 582-584

• Grant A, Eu H Trial Collaboration, Mesh compared with non-mesh methods of open groin hernia repair: systemic review of randomized controlled trials. Br J Surg 2002, 87: 854-859

• Hawasli A, et al. Laparoscopic transabdominal preperitoneal inguinal hernia repair for recurrent inguinal hernia. Am Surg 2002, 68: 303-308

• Sandbichler P, et al. Laparoscopic repair of recurrent inguinal hernia. Amer J Surg 1996, 171:366-368

• Felix EL, et al. Laparoscopic repair of recurrent hernia. Amer J Surg 1996, 172: 580-584

• Jarhult J, et al. Laparoscopic treatment of recurrent inguinal hernias: Experience from 281 operations. Surg Laparosc, Endosc & Perc Tech 1999, 9(2):115-118

• Memon MA, et al. Laparoscopic repair of recurrent hernias. Surg Endosc 1999, 13: 807–810

• Beets GL, et al. Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia? A randomized controlled trial. Surg Endosc 1999, 13: 323–327

• Ramshaw B, et al. Laparoscopic inguinal hernia repair: Lessons learned after 1,224 consecutive cases. Surg Endosc 2001, 15: 50-54

References

• Keider A, et al. Laparoscopic repair of recurrent inguinal hernia: Long-term follow up. Surg Endosc 2002, 16: 1708-1712

• Mahon D, et al. Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc 2003, 17: 1386-1390

• Neumayer L, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. New Eng J Med 2004, 350(18): 1819-1827

• Wara P, wt al. Prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia. Brit J Surg 2005, 92: 1277-1281

• Dedemadi G, et al. Comparison of laparoscopic and open tension-free repair of recurrent inguinal hernias: a prospective randomized study. Surg Endosc 2006, 20: 1099-1104

• Eklund A, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc 2007, 21:634-40

• Tantia O, et al. Laparoscopic repair of recurrent groin hernia: Results of a prospective study. Surg Endosc 2008, [Epub ahead of print]

• Knook MT, et al. Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy. 1999, 13: 1145-1147

References

• Kapiris SA, et al. Laparoscopic transabdominal preperitoneal (TAPP) hernia repair: A seven year two center experience in 3017 patients. Surg Endosc 2001, 15: 972-975

• Bittner R, Schwarz J, Recurrent Hernia; Prevention and Treatment VIII 26.3; How to treat recurrent inguinal hernia – TAPP

• Felix EL, et al. Laparoscopic repair of recurrent hernia. Amer J Surg 1996, 172: 580-584

• McCormack K, et al. Laparoscopic techniques versus open techniques for repair of a hernia in the groin. 2002 The Cochrane Collaboration

• Edwards CC, Bailey RW. Laparoscopic hernia repair : The learning curve. Surg Laprosc Endosc & Perc Tech,2000,10:149-153

• Wake BL, et al. TAPP vs TEP laparoscopic techniques for inguinal hernia repair (Review). 2008 The Cochrane Collaboration

• Crawford DL, et al. Laparoscopy identifies unexpected groin hernias. Am Surg 1998;64:976-978

• Felix EL, et al. Laparoscopic hernioplasty: Why does it work? Surg Endosc 1997;11:36-41

• Chan G, Chan CK. Long term results of a prospective study of 225 femoral hernia repairs: Indications for tissue and mesh repair. J Amer Col Surg 2008; 207: 360-367

• Mikkelsen T, et al. Risk of femoral hernia after inguinal herniorrhaphy. Br J Surg 2002; 89:486-488