Surgical Management of Inguinal Hernia

Advances in Surgery 40 (2006) 299–317

ADVANCES IN SURGERY

Surgical Management of InguinalHernia

Brian Reuben, MD, Leigh Neumayer, MD, MS*Department of Surgery, Division of General Surgery, Salt Lake City VA Healthcare System andUniversity of Utah School of Medicine, 30 North 1900 East, Room 3B110, SOM, Salt Lake City,UT 84132, USA

HISTORYInguinal hernia repair has been one of the most common operations performedby general surgeons for years. It is estimated that 700,000 hernia operations areperformed in the United States each year [1]. Until the 1980s, the most com-mon repairs were anatomic and tissue based. These types of repairs werefraught with high recurrence rates, anywhere between 1% and 15% to 20%depending on the technique and the study [2,3]. Since the mid-1980s, a newexplosion of surgical advances for the treatment of inguinal hernias has begun.As with other advances, the development of new techniques in hernia surgerywas fueled by desire to improve surgical outcomes. The push was backed bythe notion that improving recurrence rates ultimately has socioeconomic im-pacts with less work missed and quicker return to the workforce. Quality oflife is also impacted with less postoperative pain than with traditional methods.

With the understanding that hernia recurrences were because of excessivetension on the suture line, surgeons sought a way to create a tension-free repair.A variety of natural and synthetic materials were tried, including dura, aorta,pericardium, metallic prostheses, nylon, Silastic, carbon fiber, polyester, polyte-trafluoroethylene, and polypropylene [3]. Eventually, because of high rates ofinfection and rejection of the other materials, polypropylene mesh becamethe standard. The polypropylene mesh is noncarcinogenic, does not inducean inflammatory or foreign body response, does not elicit an allergic reaction,and is not altered or modified by tissue fluids [3].

Although Lichtenstein was not the first surgeon to use synthetic plastic meshfor the repair of inguinal hernias, he was the first surgeon to describe its use inthe repair of all inguinal hernias. He has been credited with coining the term‘‘tension-free’’ hernia repair. The use of synthetic mesh was previouslyreserved for large direct, large sliding, or recurrent inguinal hernias [4]. Inthe first edition of his book, 10 years before developing the current tension-free repair, Lichtenstein described using a 3 � 8 cm piece of plastic mesh to

*Corresponding author. E-mail address: [email protected] (L. Neumayer).

0065-3411/06/$ – see front matterCrown Copyright ª 2006. Published by Elsevier Inc. All rights reserved.doi:10.1016/j.yasu.2006.06.007

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300 REUBEN & NEUMAYER

reinforce the repair of direct and indirect hernias [5]. In the mid-1980s he beganto use a piece of prosthetic mesh to provide a tension-free repair for inguinalhernias, with no attempt to bring the transverses abdominus or the internal ob-lique muscle down to the inguinal ligament [4].

The Lichtenstein technique, as described by Kurzer and coworkers [4],involves injecting a mixture of 0.5% lidocaine and 0.25% bupivacaine by locallayer infiltration. A transverse skin incision is then made down to the externaloblique, where more local anesthetic is injected and allowed to flood the spacebelow the external oblique. After the external oblique is divided, more localanesthetic is infiltrated into the mesentery of the cord, the pubic tubercle,and the area of the deep ring. Direct sacs are inverted and imbricated withabsorbable suture; indirect sacs are dissected high and then inverted or ligated.The posterior wall is then covered with a 6 � 10 cm piece of mesh with a lon-gitudinal slit laterally to give a one third lower leaf and two third upper leafdistribution to the mesh. Two to 3 cm of overlap is obtained at the pubic tuber-cle and the inferior border of the mesh is sutured to Poupart’s ligament witha loose continuous suture. The superior edge is attached to the internal obliqueand conjoint tendon with interrupted sutures and one or two sutures are usedwhere the tails of the mesh cross lateral to the cord, attaching them to the in-guinal ligament and creating a snug fit around the cord. The wound is thenclosed in the usual fashion.

With the second edition of his book in 1986, Lichtenstein described hisexperience with 300 consecutive repairs with a 2-year follow-up. His resultswere astonishing, a zero percent recurrence rate. As he continued his new tech-nique, the numbers began to add up and in 1989 he published his experiencewith 1000 cases with between 1- and 5-year follow-up and still a 0% recurrencerate [6]. The results were thought unbelievable by Lichtenstein’s peers. Therewere many challenges to the validity of these results and the universality of theprocedure under the hands of the average general surgeon. An article in theAmerican Surgeon in 1992 seemed to answer the universality question. Lich-tenstein published a follow-up of 3019 hernia repairs from five diverse surgicalsources and demonstrated a recurrence rate of 0.5% and an overall 0.6% infec-tion rate [7].

With the evolution of his technique, Lichtenstein [8] advocated the routineuse of local anesthesia followed by immediate ambulation and a 1-day hospitalstay. His technique revolutionized hernia surgery by the 1990s. With increas-ing evidence that the Lichtenstein mesh repair was not only easy to performbut had excellent reproducible results, many prospective randomized trialsevaluated it against the nonmesh repairs. The EU Hernia Trialists Collabora-tion performed a systematic review of randomized controlled trials in the BritishJournal of Surgery in 2000. They noted, despite a wide range in the length offollow-up between studies, that on the whole, the incidence of recurrencewas less in the mesh groups [9]. The follow up meta-analysis 2 years latershowed the same results with a lower incidence of recurrence and less postop-erative long-term pain with the tension-free Lichtenstein method over

301SURGICAL MANAGEMENT OF INGUINAL HERNIA

traditional tension repairs [10]. With the advances in hernia surgery and the cur-rent acceptance of the Lichtenstein technique as the new gold standard for openhernia repair, the focus of this article is on the open Lichtenstein technique com-pared with the laparoscopic procedures. Before jumping into which technique isbest, one must know the various classification schemes for inguinal hernias.

CLASSIFICATION SYSTEMSAlthough many classification schemes have been proposed for hernia classifica-tion, only one system has truly stood the test of time. This is the traditionalclassification of groin hernias into indirect, direct, and femoral [11]. The ideabehind the development of more descriptive classification schemes has beento compare hernia outcomes for various hernias of increasing complexity.The new classification schemes take into account the anatomic location ofthe hernia; the size of the hernia; and if any other complicating factors, suchas combined indirect and direct hernias (pantaloon), exist. Despite the bestattempts to create a grading system for stratification, they are seldom used inclinical trials. Many different classification systems have been proposed (Table 1).No one system is perfect or universally accepted. The ideal classification sys-tem would contain several features: it would be based on anatomic locationand include anatomic function (such as the competency of the internal ring andintegrity of the direct floor); it would also include the defect size and the degreeof sac descent, be reproducible and useable with various surgical approaches,and easy to remember [11]. The authors have chosen to reproduce the Nyhusclassification of groin hernias because this is one of the more widely acceptedsystems (Table 2).

TECHNIQUES OF HERNIA REPAIROpen anterior approachAlthough surgeons had been repairing hernias for many years, it was not untilthe late 1700s and early 1800s when the surgical anatomists published their

Table 1Classification systems for inguinal herrias

Classification Year proposed

Harkins 1959Halverson and Mc Vay 1970Lichtenstein 1987Gilbert 1987Nyhus 1993Bendavid 1994Nyhus with Stoppa modification 1998Alexandre 1998Schumpelick Aus Arti-Aachen 2002

Adapted from Zollinger R Jr. Classification systems for groin hernias. Surg Clin North Am 2003; 83:1079–98; with permission.


works on the detailed anatomy of the inguinal canal did the successful repair ofan inguinal hernia begin to take form. The operations have varied over thecourse of time, but the anatomic concepts remain unchanged. In 2003, Rutkow[12] estimated the most popular hernia repair technique in the United States tobe the Lichtenstein at approximately 295,000 or 37% of all repairs; this wasfollowed by the Plug method at 270,000 or 34%, and laparoscopy at 115,000or 14% of all hernia surgeries.

Although the Lichtenstein repair described previously is the most popular inthe United States, the PerFix plug (Bard, Murray Hill, New Jersey) repair isanother open anterior approach frequently used. It is covered briefly forcompleteness. In mid-1993 the C.R. Bard Company began to market a pre-formed umbrella-shaped hernia plug called the PerFix, made of marlexmesh. This was the first ready-to-use mesh hernia device. The device washeat molded to fix the shape but it did allow for the ability of the surgeon tomodify some of the petals to the individual anatomy of each patient. Rutkow[13] pioneered the use of the PerFix plug and advocates a high but not exten-sive dissection of the indirect sac with placement of the PerFix plug insertedinto position in the internal ring, just beneath the crura. This is fixed in placewith one to two Vicryl stitches. Outcomes are generally similar to the Lichten-stein method [14], and a randomized clinical trial found no difference in theshort-term or long-term pain in 334 patients randomized to Lichtenstein versuseither mesh plug or the plug and patch system [15]. Recurrence rates are lowfor direct and indirect hernias (2% and <1%); however, in recurrent hernias

Table 2Nyhus 1993 classification of groin hernias

Type Description

Type I Indirect, smallNormal internal ringSac in canal

Type II Indirect, mediumEnlarged internal ringSac not in scortum

Type III A: DirectFloor only

B: Combined—indirect largeEncroaching into direct floor

C: Femoral

TYPE IV RecurrentA: DirectB: IndirectC: FemoralD: Combinations of A, B, and C

From Nyhus LM. Individualization of hernia repair: a new ear. Surgery 1993;114:2; with permission.


rates as high as 13% are seen, which suggests use of the PerFix plug in thesecases may not be ideal [13].

The Prolene Hernia System (Ethicon, Sonerville, New Jersey) is a combina-tion onlay patch and underlay tension-free patch inserted through an anteriorsurgical approach. It is marketed for direct, indirect, and femoral hernias. Theonlay and underlay patches combine all the benefits of anterior and posteriorrepairs. The underlay patch is placed through the internal ring or throughthe transversalis fascia, in the preperitoneal space. This system effectivelycovers the femoral, anterior, and lateral triangles of the groin, lowering therisk of recurrence [16]. Early results of this patch in clinical use are encouragingwith a low incidence of hernia recurrence [17]. A recent randomized blindedstudy evaluated the difference in postoperative pain between the Lichtenstein,mesh plug, and the Prolene Hernia System and found no difference in post-operative pain or quality of life [15].

Open posterior approachNyhus and coworkers [18] was the first to describe a preperitoneal tissue repairin 1960. This repair was championed especially for recurrent hernias and thoseinvolving incarcerated or strangulated bowel. Once the preperitoneal space isaccessed, usually through a skin incision a little higher than the usual groinincision, the hernia is reduced and the transversalis fascia is reapproximatedto the iliopubic tract using monofilament interrupted sutures. Nyhus andcoworkers [19] recommended buttressing the repair of any large hernia witha sheet of polypropylene mesh. He reported a recurrence rate of 3% for indi-rect, 6% for direct, and 1% for femoral hernias [20].

Stoppa and Quintyn [21] described placing a large piece of prosthetic mesh inthe preperitoneal space in 1969. The initial description of the giant prostheticreinforcement of the visceral sac involved placing an unsutured giant pieceof mesh (extending from just shy of one anterior superior iliac crest to the otherand from the umbilicus to the pubis) without attempting any tissue repair. Stoppa[22] reported a 1.4% recurrence rate using this repair. Muldoon andcoworkers [23] reported a randomized trial involving 247 men comparinga version of the preperitoneal repair with Lichtenstein repair. The recurrencerates were statistically similar between the two repairs (<1% and 4.3%, re-spectively; P ¼ .21).

The open posterior approach using the Kugel patch (Davol, Cranston, RhodeIsland) for repair of inguinal hernias was designed to combine the ease of theopen approach with the advantages of minimal access surgery. This procedurehas been described as a ‘‘touch-and-see’’ procedure by its creator, is highly de-pendent on the surgeon’s understanding of the anatomy of the preperitonealspace, and takes full advantage of the intra-abdominal pressures to help securethe mesh [24]. The self-expanding bilayer polypropylene patch (small size, 8 �12 cm; medium size, 11 � 14 cm) is inserted through a 4-cm muscle-splittingincision into the preperitoneal space once the hernia sac has been reduced ordivided. It is designed to cover the symphysis pubis, continue over the inguinal


ligament, the direct space, the femoral space, and laterally over the indirectspace. There have been no large-scale prospective trials comparing the Kugelrepair against anterior approaches for postoperative pain control or return towork, but most patients report low pain scores, similar to those for laparoscopicrepairs [25]. Kugel’s [24] own results are excellent with an overall recurrencerate of 0.4%. Others have not been able to duplicate these outstanding results,however, and recurrence rates vary between 1% and 27.8% [25,26].

It has been found that half of all recurrences after an open repair occur after5 years and 75% occur within 10 years after surgery [27]. Stoppa, however,believed that all of his recurrences occurred within the first year and werecaused by technical factors [28]. In the experience of Reddy and coworkers[25] with the Kugel repair, the author believed that all four recurrences inthe study were technical mistakes with incomplete dissection of the medialand inferior border of the preperitoneal space. For the Lichtenstein repairs, re-currences are thought to be mainly caused by a failure to diagnose multiple her-nias at the time of the initial operation, failure to close an enlarged internal ring,and inadequate overlap of the mesh medially [29].

Evolution of the laparoscopic repairDuring this same period, while the Lichtenstein open repair was proving itsworth against the traditional open nonmesh repairs, laparoscopic surgerywas born. Surgeons quickly began to develop operations for the repair of ingui-nal hernias. Early laparoscopic techniques for the repair of inguinal herniaswere compared with open nonmesh techniques (Bassini, McVay, and Shoul-dice) and were found to be superior with regard to postoperative recoverywith earlier return to work and normal activities; less postoperative pain;and lower recurrence rates (3% compared with 6%) [30,31]. The benefits oflaparoscopic mesh repair compared with open mesh repair, however, have notbeen as clear-cut. Many proponents of laparoscopic repair cite reduced post-operative pain and recovery time, the ability to inspect both inguinal regionsand repair concurrent contralateral hernias concomitantly, the ease of treatmentof recurrent hernias with avoidance of the scarred operative site, and the ability touse mesh to cover the entire myopectineal orifice with adequate overlap [3].

The first transabdominal preperitoneal laparoscopic technique (TAPP) wasperformed in 1992 by Dion and Martin [32] and later modified by Corbitt[33]. In this technique, entry into the peritoneal cavity is obtained and the um-bilical trocar is placed followed by two additional 5-mm trocars, usually in eachlower quadrant, just lateral to the rectus muscle. A transverse peritoneal inci-sion is made from the medial umbilical ligament laterally to the internal ring.The preperitoneal contents are bluntly dissected exposing the myopectinealorifice and the hernia is reduced. A large 10 � 15 cm piece of mesh is usedif not anchored, or a smaller piece can be used if fixation is used. The entiremyopectineal orifice needs to be covered with at least a 2.5-cm overlap. An en-doscopic stapler can be used to fix the mesh and this covers any indirect, direct,or femoral defect. The peritoneal flaps are then closed.


The first totally extraperitoneal repair (TEP) of an inguinal hernia is creditedto McKernan and Laws in 1992 [34]. This repair uses the potential spacebetween the peritoneum and the abdominal wall musculature. As describedby Davis and coworkers [28], a specially designed inflatable balloon dissectoris used to create the space, which is maintained by CO2 insufflation. The dis-section can also be done under direct vision. Two additional 5-mm trocars areplaced in the midline. Similar to the TAPP procedure, the entire myopectinealorifice is exposed; the hernias are reduced; and a large piece of mesh is placedover the defect and usually stapled into place, although not necessary (Figs. 1and 2). Early studies and recent ones have demonstrated the safety and efficacyof the laparoscopic hernia techniques [35–37]. A recent Cochrane databasereview [38] and a systematic review by McCormack and coworkers [39]have not been able to determine the superiority of TEP versus TAPP.

A criticism of both the TEP and TAPP procedures deals with the prolongedoperative times when compared with open procedures. Schwab and coworkers[40] point out that once general surgeons progress along the learning curve forthe laparoscopic repair, operative times are equal to or faster than the times foropen repairs. Pawanindra and coworkers [41] looked at TEP inguinal repairand noted that operative times were less than half when examining timesfrom the first 10 cases and comparing them with times beyond the 30th case.It has also been noted that complication rates in the early to mid 1990s for lap-aroscopic repair, which were 10 times greater than open repair, are no longerseen [42–44].

Another potential downside of the TEP and TAPP repairs for inguinalhernia involves the difficulty with or contraindication for future pelvic surgery.This theoretical notion was raised several years ago and early case reports ofdifficulties with radical retropubic prostatectomy after previous laparoscopicinguinal hernia repair began to appear in the literature [45,46]. The argumentswere that a dense inflammatory and fibrotic reaction obliterates the space ofRetzius making radical retropubic prostatectomy difficult to impossible andwith physical attachment of the bladder to the mesh, increases a patient’srisk of incomplete tumor removal, bladder perforation, or tumor spillage forresection of certain carcinomas of the bladder [46]. Arguments were madefor prostate cancer screening (digital rectal examination and prostate-specificantigen level) in all men over the age of 30 who are in consideration for a lap-aroscopic inguinal hernia repair. As more data are published on this topic, how-ever, it seems that previous laparoscopic inguinal hernia repair with mesh doesnot adversely affect outcomes, functional results, or complications after radicalprostatectomy [47]. It does make the procedure more demanding and is not anabsolute contraindication [48].

The patterns of recurrence for laparoscopic hernia repairs are different thanfor open repairs. The two most common causes of recurrence are thought to becaused by incomplete dissection of the myopectineal orifice and inadequate sizeof the mesh (Box 1) [28]. Phillips [49] noted that after laparoscopic repair, 60%of recurrences were caused by mesh that was too small. In the same study, in


32% of recurrences, no staples were used. Although a small study, Bingener andcoworkers [50] published the results of a recent 27-month follow-up of 35 of 37laparoscopic (TEP and TAPP) hernia repairs and noted a 2.5% recurrence rate.Although most open hernia repairs recur medially, the opposite is true forlaparoscopic repairs, and these are likely overlooked indirect hernias [51].The Achilles heel of the laparoscopic repair is lateral, whereas with the openrepair it is medial. As experience with this technique improves, the previouslyreported 10% to 20% recurrence rates in the early 1990s will be reducedsignificantly.

Open versus laparoscopic trialsAlthough the benefits of the tension-free methods for inguinal hernia repairhave been well understood (open Lichtenstein and laparoscopic methods), itis less clear whether the open or laparoscopic procedure is superior. The mea-sure of superiority can be evaluated on many different levels. One could

Fig. 1. Dissecting the hernia sac off the cord structures in a laparoscopic TEP repair.

Fig. 2. Mesh placement around the cord structures in a TEP repair.


compare recurrence rates between the two procedures; time to return to work;and daily activities or pain scores, both for chronic and postoperative pain. Aspreviously discussed, the Lichtenstein method is well studied and the resultsare reproducible. Is it better to perform laparoscopic hernia repair or is theopen technique superior?

There has been an explosion of research into this question over the past 10years. Just 2 years ago there were four meta-analyses, two systemic reviews,and nearly 70 randomized controlled trials [28]. In the last 2 years, severalmore meta-analyses have been published and the largest prospective random-ized trial to date comparing open with laparoscopic mesh hernia repair[44,52]. The randomized trials to date have a great deal of variability withregard to the quality of the data. The published results for several outcome

Box 1: Causes of inguinal hernia recurrence after laparoscopicrepair

Evolution of technique

Inexperience (learning curve)

Incomplete dissection

Missed hernia

Missed lipoma of cord or of direct hernia

Inadequate reduction of direct hernia sac

Inadequate dissection of proximal indirect sac from cord

Rolling of mesh

Mesh size and configuration

Too small (inadequate overlap of defect or migration of mesh)

Configuration (slit or keyhole)

Mesh fixation

Mesh poorly fixed laterally

Mesh poorly fixed medially

Clips pulled through

Mesh never stapled (fixation versus nonfixation)

Mesh displacement

Hematoma

Seroma

Migration

Rolling of mesh

Shrinkage

From Davis CJ, Arregui M. Laparoscopic repair for groin hernias. Surg Clin North Am2003;83:1151; with permission.


measures are often contradictory between studies, which intensify the debatebetween which procedure is better. Many of the studies have low power andcompare mixed groups of patients (often conventional tissue repairs are mixedin with tension-free mesh repairs). Meta-analyses solve the problem of powerand perhaps the most thorough are the European Union Hernia TrialistsCollaboration [10], the UK group of Memon and coworkers [44], and theGerman group of Schmedt and coworkers [53].

The EU Hernia Trialists Collaboration is a group of 70 investigators from20 different countries who analyze data from randomized trials and publishit in meta-analysis form. Their first review in 2000 reported recurrence ratesbetween laparoscopic and open methods that were not statistically significant[54]. The studies used were quite varied and the trials ranged in size from20 to 1051 with follow-up from 6 weeks to 36 months, clearly not an idealgrouping of studies. The other end points studied (postoperative pain, returnto usual activity, and so forth) trended toward one procedure but the variationin reporting between studies prevented a formal meta-analysis [54]. A follow upmeta-analysis by the EU Hernia Trialists Collaboration in 2002 was moredefinitive [55]. They analyzed a total of 4165 patients from 25 trials. The cate-gories were compared by TAPP versus mesh, TAPP versus nonmesh,TAPP versus mixed open, TEP versus mesh, TEP versus nonmesh, andTEP versus mixed open. The formal conclusions from this study were thatreturn to normal activity is faster after laparoscopic repair, persistent pain isreduced after laparoscopic repair, and the recurrence rate is lower for laparo-scopic repair versus nonmesh repair but recurrences are the same for laparo-scopic versus open mesh repair. Of note, there was no difference in the rateof complications (intraoperative or postoperative) between the laparoscopicand open groups. This study did not address cost issues or recurrent or bilat-eral hernias.

A newer meta-analysis of randomized clinical trials comparing open and lap-aroscopic hernia repair is from Memon and coworkers [44] in 2003. This studycompared 29 trials with 5588 patients and 5989 hernia repairs. They looked atsix outcome variables: (1) operating time, (2) time to discharge from hospital,(3) return to normal activity, (4) return to work, (5) postoperative complica-tions, and (6) hernia recurrence rate. Trials were grouped according to thetype of procedure. Unfortunately, the study did not separate open proceduresinto mesh and nonmesh. Unlike the EU Collaboration analysis, however, thestudy did surprisingly favor open hernia repair over laparoscopic. Despite theirlack of separation of tension-based and tension-free repairs, the relative odds ofshort-term recurrence were higher in the laparoscopic group, although this wasnot statistically significant [44]. Interestingly, it did reach statistical significancewhen laparoscopic repair was compared with tension-free open repair. Thestudy did show a statistically significant increase in operating time and a trendtoward earlier discharge from the hospital after laparoscopic hernia repair. Forthe remaining outcomes, return to normal work activity and return to workand postoperative complications favored the laparoscopic method of repair.


Another recent meta-analysis by Schmedt et al [53] in 2005 evaluated 34 ran-domized controlled trials for laparoscopic versus Lichtenstein and other openmesh repairs with a total of 7223 patients. In this study, the authors foundthe laparoscopic approach to have the advantages of earlier return to normalactivities or work and fewer incidences of chronic pain syndrome. The Lichten-stein repair, however, was found to have shorter operating times, lower inci-dence of seroma formation, and fewer hernia recurrences. The recurrencedata were strongly influenced by the VA Hernia Trial with 1983 patients inthe study compared with the other studies where the range was from 18 to915 study participants. A recent prospective randomized trial of 168 patientsfrom Sweden has agreed with the results of the larger meta-analyses. Theycompared TEP with open Lichtenstein and found the TEP group to have sta-tistically less postoperative pain, earlier return to work, and shorter time to fullrecovery with a trend toward more recurrences in the laparoscopic group [56].

One of the landmark clinical trials evaluating open mesh versus laparoscopicmesh repair of an inguinal hernia is the VA Cooperative Study 456 [52]. In thisstudy, Neumayer and coworkers [52] prospectively randomized 2164 patientsto open mesh repair versus laparoscopic mesh repair to evaluate the primaryoutcome of recurrence of the hernia at 2 years. With 85.5% 2-year follow-up, the authors noted a higher recurrence in the laparoscopic group (10.1%)compared with the open tension-free group (4.9%). The types of open herniasthat tended to recur more often were Nyhus class III hernias (see Table 1).Rates of recurrence for recurrent inguinal hernias were similar, however,among the two groups. Interestingly, the operative times for open and lapa-roscopic repair of inguinal hernias were the same [51]. The rate of complica-tions was higher in the laparoscopic surgery group than in the open group.This study also confirmed the findings of other studies with respect to life-threatening complications. The laparoscopic group had more frequent intra-operative, immediate postoperative, and life-threatening complications whencompared with the open group, but the rate of long-term complications wassimilar between the two groups. For evaluation of postoperative pain, theopen group had greater level of pain immediately postoperative and at 2 weeks,although the difference was small (10 mm maximum on a 150-mm visualanalog scale). At the 3-month follow up, there was no difference between thetwo groups.

It is known that the laparoscopic procedure is generally more difficult tolearn compared with the open Lichtenstein method [57]. The laparoscopic pro-cedure has a very steep learning curve and recurrence rates can be as high as20% when surgeons are first learning the technique [58]. Lowham andcoworkers [59] found that for surgeons with greater than 50 laparoscopic ingui-nal hernia repairs, recurrence rate was less than 1%. Other authors have cometo similar conclusions: the learning curve becomes less steep around 30 to 50laparoscopic cases [60–62]. A post hoc analysis in the VA Hernia Trial evalu-ated the association between surgeons’ self-reported experience with laparo-scopic procedures and recurrence rates. This analysis revealed a difference in


recurrence rate based on surgeon experience. Surgeons with greater than 250laparoscopic cases had a recurrence rate of 5%, whereas those with less expe-rience had a recurrence rate of 10% [57]. There was no significant differencebetween the recurrence rates in the open group based on surgeon experiencein the VA Hernia Trial.

Additional considerations in open versus laparoscopic repairsBilateral herniasA recent small prospective randomized trial evaluated TAPP versus open meshrepair for bilateral and recurrent inguinal hernias [63]. One hundred andtwenty patients were randomized to either TAPP or open mesh repair. Theprimary study outcome was postoperative pain, but they also evaluated well-being, postoperative mobilization, return to work, recurrence rate, chronicpain, and complications. Patients undergoing laparoscopic surgery for bilateralor recurrent hernias had statistically significant less postoperative pain com-pared with the open group. With a small sample size and only 3-monthfollow-up, the study was underpowered and not lengthy enough to determinesignificant differences in recurrence and chronic pain. Many authors believe,however, that one of the indications for laparoscopic hernia repair is the occur-rence of bilateral hernias. Both sides can be operated on with the same trocarplacements without the additional morbidity of bilateral traditional incisions.This debate is not clear-cut because the VA Hernia Trial showed no increasein recurrence or complications in either open or laparoscopic groups whenbilateral hernias were repaired simultaneously [52]. One study exclusively eval-uating the simultaneous repair of bilateral and recurrent hernias has only 43patients [64]. Results favored the laparoscopic repair, however, for postopera-tive comfort and return to work.

Recurrent herniasThe management of recurrent inguinal hernias is an area of considerable de-bate. Historically, recurrence rates after traditional tissue repair of a recurrentinguinal hernia can range from 8% to 34% [65,66]. The laparoscopic repair fora recurrent hernia has become increasingly popular for theoretical and clinicalreasons. In theory, if the patient has received an open anterior repair first, thepreperitoneal tissues are still virgin making dissection much easier. As a result,there may be reduced trauma to the cord structures, including devasculariza-tion of the testicle in males. Also, in the event of a missed hernia during theinitial repair, one has better visualization in a clean operative field. Authors re-port recurrences for laparoscopic repair of a recurrent hernia anywhere from<1% in retrospective studies [67] to 10% to 12.5% in randomized controlled tri-als [52,66]. Recurrence rates for open Lichtenstein repair of a recurrent inguinalhernia varies between 1% for retrospective reviews to 14% in randomized con-trolled trials [52,68]. Evidence for improved pain control and quicker return towork exists for laparoscopic repair of recurrent inguinal hernias [66,69,70]. Sur-geons have even proved that it is feasible to perform a TEP repair for recur-rence after a previous TEP repair. Ferzli and coworkers [71] have performed


19 safe re-do TEP repairs and have no recurrences or major complications atan average follow-up of 51 months. Better randomized control trials are stillneeded to evaluate further whether open or laparoscopic repair for recurrenthernias is superior.

CostsCost analyses comparing laparoscopic and open techniques for hernia repairare difficult to evaluate. It is easy to quantify known, direct costs. There aremany hidden costs and indirect costs, however, which can be quite variable be-tween hospitals and patients. Most studies are not complete, leaving out thecost of recurrences, or are old and compare tissue repair with laparoscopicmesh repair. Swanstrom has published several papers on cost-containmentfor laparoscopic surgery [72,73]. He believes that with cost-containment mea-sures (eliminating unnecessary items and using less expensive instruments)the cost for laparoscopic repairs approaches that of open repairs and will betterit in the case of bilateral hernia repairs [72]. Other studies argue that whereaslaparoscopic procedures have higher costs, they are offset by a decreased lengthof hospital stay and an earlier return to work, such as Feliu and coworkers [74]in their 10-year review of recurrent inguinal hernias. In one study, an earlierreturn to work with less missed days was found to offset the higher costs ofthe laparoscopic procedure and have implications in terms of socioeconomicimpact [75].

Patient-reported outcomesChronic pain has been a significant problem in inguinal hernia surgery.Chronic pain can be experienced by greater than 20% of individuals undergo-ing open hernia repair 12 months after surgery and younger patients are atgreater risk for developing chronic pain syndromes [76,77]. The Medical Re-search Council in Great Britain noted a 37% incidence of residual pain afteropen and a 27% incidence after laparoscopic hernia repairs [78]. There hasbeen no correlation between pain and the type of hernia, defect size, experienceof the operating team, length of the incision, and operating time [79]. The im-pact of chronic pain has major implications for quality-of-life issues and healthcare costs. For most studies, pain is a secondary measurement and not the pri-mary outcome parameter. Madura and coworkers [79] pooled patients fromvarious studies for a total of just over 24,000 patients and claim that the inci-dence of postoperative pain is calculated to be 4.5% for open procedures and17.3% for laparoscopic procedures.

In the VA Hernia trial, a visual analog scale was developed to assess surgicalpain and was found to be very reliable [80]. In this study, the laparoscopicgroup had less pain initially when compared with the open group, but thetwo groups were similar by the time of the 3-month postoperative visit(Fig. 3). Grant and coworkers [81] evaluated pain and numbness with a postalquestionnaire after a large randomized trial between open and laparoscopic ten-sion-free hernia repairs. In their findings, fewer respondents in the laparoscopicgroup had groin pain, but this did not reach statistical significance. At this


point, there is no clear division between the laparoscopic and open groups forchronic pain. In a more radical approach to the chronic pain issue, Picchio andcoworkers [82] looked at elective division of the ilioinguinal nerve to reduce theincidence of chronic postoperative pain in a recent randomized control study.The authors found no difference in chronic pain between the two groups, onlya significantly greater loss of pain or touch sensation in the group of patientswho had their nerve divided.

The surgical treatment of chronic pain is an area of recent research. A groupin Indiana recently published their results for inguinal neurectomy for inguinalnerve entrapment in 100 patients. They had good results from inguinal neurec-tomy with total pain relief in 72% of patients with proximal nerve resection andalcohol or phenol application [79]. Most of these chronic pain syndromes seemto be caused by injury from suture, adherence to the overlying mesh, or in-volvement in scar tissue. Aasvang and coworkers [83] evaluated 14 studieson the surgical management of chronic pain after inguinal hernia repair and

Fig. 3. Differences in open-repair and laparoscopic-repair groups in pain scores on a visualanalog scale over time, after adjustment for stratification factors. A value above 0 indicatesmore pain in the open-repair group than in the laparoscopic-repair group, and a score below0 indicates more pain in the laparoscopic-repair group than in the open-repair group. Horizon-tal lines represent the 95% confidence intervals. (From Neumayer L, Giobbie-Hurder A., Jon-asson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med2004;350:1819–27; with permission.)


found insufficient support for removal of the mesh or staples for treatment ofthe pain. The ilioinguinal nerve is most at risk for entrapment because it liesjust beneath the external oblique fascia and can easily be included in the sutureof the mesh or closure of the external oblique muscle. A good understanding ofthe surgical anatomy and careful dissection may be crucial to preventing thesetypes of occurrences.

AnesthesiaSeveral studies in both the general surgery and anesthesia literature havelooked at pain control during surgery and immediately postoperative. Open in-guinal hernia repair can be performed under local anesthesia, with or withoutsedation or monitoring in >90% of cases and this is done almost exclusively inthe hernia specialty centers [84]. In a multicenter randomized trial, local anes-thesia was compared with regional and general anesthesia for open hernia re-pair. Local anesthesia was found to be superior in the early postoperativeperiod but no difference was seen at 8 and 30 days [85]. The pain scoreswere highest for the general anesthetic group. Although the paper did not spec-ify the types of open procedures, whether they were tissue-based or tension-free, it does highlight the importance of adequate local infiltration of anestheticfor immediate postoperative patient comfort. Early postoperative complicationswere also higher in the regional anesthesia group when compared with the localanesthetic group; this included the need for catheterization for difficulty urinat-ing (28% compared with 0%) [85]. Along these lines, Andersen and coworkers[86] have shown that the addition of an ilioinguinal blockade significantly im-proves intraoperative pain scores when added to local anesthesia alone. Instill-ing local anesthetic into the preperitoneal space after laparoscopic TEP repairmay also be beneficial in attenuating postoperative pain. Although a small study,Bar-Dayan and coworkers [87] compared pain levels postoperatively at 1, 2,and 4 hours in 44 patients and noted a significantly lower pain score at all threetimes in those patients who received preperitoneal bupivacaine. Finally, the ad-dition of a cyclooxygenase-2 inhibitor preoperatively and postoperatively (rofe-coxib) may also help attenuate postoperative pain scores in open inguinalhernia repairs [88]. Caution must be used to select the appropriate patientpopulation.

SUMMARYThe Lichtenstein repair is now the gold standard for open hernia repairs. Thisrepair is easier to learn and easy to implement for the average general surgeon.Open mesh repairs are not the end-all in hernia operations, however, and sur-geons must retain the knowledge for open tissue-based procedures. Laparo-scopic inguinal hernia repair is a safe alternative to open repair for inguinalhernias but is much more operator dependent. Open mesh repair has a lowerrecurrence rate when compared with TEP or TAPP repairs for less experi-enced laparoscopists. Laparoscopic repair has a quicker return to work, is as-sociated with less postoperative pain, and has a better cosmetic result. It is


more difficult to learn, however, and hospital costs are higher. Surgeons need tolook at their own numbers and experience to decide which approach is bettergiven the clinical situation based on their proficiency with the various techniques.

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Surgical Management of Inguinal Hernia

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