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INTRODUCTION — Minimally invasive surgical approaches are increasingly popular because they offer the potential for less postoperative pain and a quick return to normal activities. Laparoscopic repair of inguinal and femoral hernia is no exception, with laparoscopic approaches first used to treat inguinal hernias in 1992 . The learning curve for laparoscopic hernia repair is prolonged with estimates ranging between 50 and 100 procedures. However, when performed by an experienced surgeon (>100 repairs), hernia recurrence is low .
Laparoscopic repair of inguinal and femoral hernias is discussed here. The classification and diagnosis of inguinal and femoral hernias, treatment approach, and open surgical techniques for inguinal and femoral hernia repair are discussed elsewhere. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults" and "Overview of treatment for inguinal and femoral hernia in adults" and "Open surgical repair of inguinal and femoral hernia in adults".)
ANATOMIC CONSIDERATIONS — A clear understanding of the anatomy of the groin and its anatomic approaches is important for successful laparoscopic hernia repair (picture 1A-C). The general anatomy of the abdominal wall and groin region and the course of the nerves to the abdominal wall are discussed elsewhere. (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Anatomic considerations' and "Open surgical repair of inguinal and femoral hernia in adults", section on 'Nerves of the groin region'.)
Laparoscopic repair approaches — When performing laparoscopic inguinal or femoral hernia repair, the hernia defect is approached from its posterior aspect and the repair involves placing mesh in the preperitoneal space (figure 1). The anatomic approach to the preperitoneal space depends upon the laparoscopic technique used for hernia repair. The two commonly used approaches to laparoscopic repair of inguinal and femoral hernias are the transabdominal preperitoneal hernia repair (TAPP) and the totally extraperitoneal hernia repair (TEP) approaches.
TEP repair — TEP is performed in the preperitoneal space and was developed to avoid the risks associated with entering the peritoneal cavity [3,4]. The surgeon develops a space between the peritoneum and the anterior abdominal wall so that the peritoneum is never violated. In experienced hands, this approach has the advantage of eliminating the risk of intraabdominal adhesion formation [4,5].
TAPP repair — TAPP repair involves the placement of mesh in a preperitoneal position, which is covered by peritoneum to keep the mesh away from the bowel. Because TAPP is performed transabdominally, it has a larger working space than TEP, with ready access to both groins, and can be attempted in patients with prior lower abdominal surgery. However, TAPP can result in injuries to adjacent intraabdominal organs, adhesions resulting in intestinal obstruction, or bowel herniation [5,6].
TAPP herniorrhaphy can be performed with or without robot assistance. Robot-assisted TAPP repair has the same indications as the standard TAPP repair . The use of a robot allows for easier suture fixation of the mesh. However, no patient outcome data have been reported for this technique.
INDICATIONS FOR LAPAROSCOPIC REPAIR — The definitive treatment of most hernias, regardless of their origin or type, is surgical repair [2,8-10]. The indications for inguinal and femoral hernia repair in adults are discussed elsewhere. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Indications for surgical repair'.)
The laparoscopic approach to inguinal hernia repair is theoretically possible in nearly all inguinal hernias. However, the precise role of laparoscopy in inguinal hernia repair remains somewhat controversial given the increased costs and greater technical demands . The laparoscopic approach is preferred by many surgeons for bilateral, recurrent, and femoral hernias. The choice between open and laparoscopic inguinal and femoral hernia repair is discussed elsewhere. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Choosing a surgical approach'.)
Contraindications — Factors that may contraindicate a laparoscopic approach, and thus favor an open approach, are listed below and are discussed in greater detail elsewhere. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Patients precluded from laparoscopic repair'.)
●Inability to tolerate general anesthesia
●Prior pelvic surgery in the preperitoneal space
●Incarcerated inguinal hernia
●Large scrotal hernia
PREOPERATIVE EVALUATION AND PREPARATION — Preoperative evaluation and preparation prior to inguinal and femoral hernia repair, including thromboprophylaxis, prophylactic antibiotics, initial management of complicated hernia, and choice of anesthesia, are discussed separately. Some surgeons require all patients undergoing laparoscopic groin hernia repair to have a bladder catheter in place prior to beginning the procedure to decompress the bladder and reduce the risk of bladder injury. Others use bladder catheterization selectively in patients who are at risk for developing bladder distension during the procedure or urinary retention after the procedure. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Preoperative preparation'.)
Equipment — Appropriate instrumentation and supplies should be readily available, and the proper functioning of laparoscopic imaging equipment verified prior to initiating anesthesia. An angled laparoscope, usually a 30° or a 45° scope, is used for these procedures, which allows for better visualization than a non-angled laparoscope. (See "Instruments and devices used in laparoscopic surgery".)
●10 mm 30° laparoscope
●Trocars - (2) 5 mm, (1) 10 to 12 mm
●Preperitoneal balloon dissector (eg, Spacemaker, Covidien), TEP only
●Polypropylene mesh, flat or preformed (eg, Bard 3D Max preformed mesh)
●Laparoscopic tack or strap applier (eg, Bard, Covidien, and Ethicon)
●Laparoscopic clip applier
Mesh for laparoscopic repair — Mesh is a necessary element of laparoscopic inguinal and femoral hernia repair to provide a tension-free hernia repair, which is the recommended method [12-14]. Preformed mesh that conforms to the preperitoneal space is available and is preferred by some surgeons over a flat piece of mesh that needs to be trimmed to accommodate the patient's anatomy. The particular product or the method used for placement is a matter of personal preference.
Polypropylene woven mesh (eg, Marlex, Prolene, SurgiPro) has been used in essentially all studies describing laparoscopic hernia repair and is preferred over other prosthetic materials. Expanded polytetrafluoroethylene (ePTFE, Gore-Tex) is another material that is used extensively for incisional hernias, but it has not been used for the laparoscopic inguinal and femoral hernia repair except for the intraperitoneal onlay mesh (IPOM) technique. ePTFE provokes less of an inflammatory response, a process that is believed to be particularly important in inguinal and femoral hernia repair. There are no direct trials comparing the two materials, and in the absence of data describing the use of ePTFE for TEP or TAPP hernia repairs, we suggest using polypropylene mesh for laparoscopic inguinal and femoral hernia repair. (See "Reconstructive materials used in surgery: Classification and host response".)
Polypropylene mesh is commercially available in light, medium, or heavy weight. In a systematic review of patients who had laparoscopic inguinal hernia repair, the use of a light-weight mesh, as opposed to a heavy-weight mesh, was associated with a lower incidence of chronic groin pain, groin stiffness, and foreign body sensations without any increased risk for hernia recurrence .
Patient positioning — The patient is usually placed in 15° to 20° of Trendelenburg position to improve exposure of the working area, which is particularly important with TAPP hernia repair to move the small bowel away from the area of dissection.
CHOICE OF PROCEDURE: TEP OR TAPP? — There are limited data comparing the safety and effectiveness of TEP with TAPP .
For surgeons with expertise in both techniques, we suggest the totally extraperitoneal (TEP) technique for most male patients. For patients in whom the TEP technique is not appropriate or fails due to inability to develop the preperitoneal space, conversion to a transabdominal preperitoneal (TAPP) approach can be performed. On occasion, conversion to an open surgical approach may be necessary. Larger hernias, especially large scrotal hernias, are probably best repaired open. In female patients with indirect inguinal hernia, a TAPP approach may be easier. Indirect inguinal hernia sacs are frequently much more intimately attached to the round ligament in women than are indirect sacs to the cord structures in males. In a large series of hernia repairs in women, the TAPP repair produced the best outcomes, with low recurrence rates .
A single randomized trial found less postoperative pain after TAPP, but shorter hospital stay with TEP . A systematic review that included this trial and eight retrospective studies found a lower risk of visceral injury (small bowel, bladder), deep mesh infection, and incisional hernia with TEP repair . However, the risk of vascular injury (typically inferior epigastric artery) or conversion to an open procedure was lower with TAPP repair. A later review evaluated complications and hernia recurrence rates for TEP and TAPP in studies performed between 1990 and 1998 with those performed from 1999 to 2008 . Overall complications and recurrence rates improved in the second decade with increasing surgeon experience, and no significant differences were identified between the techniques.
Both approaches are acceptable and one approach may be preferred over the other under specific clinical circumstances. TAPP was the original approach, and TEP evolved to address some of the problems associated with TAPP, but TEP repair is technically more challenging because of the limited working space, which may explain higher conversion rates. Most surgical trainees in the United States learn TEP. Outside of the United States, a TAPP approach may be more commonly used . Although surgeons should learn both techniques, they should use the technique with which they are most familiar.
•Intraabdominal adhesions – TEP avoids the abdominal space; however, if the peritoneum is violated during the course of dissection, it is important to close the peritoneal defect to minimize adhesion formation.
•Can be used without general anesthesia – Rarely, TEP has been successfully accomplished with neuraxial or local anesthesia with sedation [20-24]. However, patients who cannot tolerate general anesthesia should generally undergo open inguinal herniorrhaphy instead of laparoscopic repair.
•Bilateral hernia – In a TEP repair, a single balloon dissection develops working spaces in both groins, enabling placement of large pieces of mesh. With a TAPP approach, bilateral repair requires two separate peritoneal incisions and dissections, which increase operative time and risk (eg, adhesion formation, bowel obstruction or herniation). Nevertheless, some surgeons still prefer a TAPP approach for bilateral hernia repair .
•Prior pelvic surgery – In the face of prior preperitoneal pelvic dissection, it may not be possible to develop the proper exposure for TEP repair.
•Occult hernia – For patients in whom a groin hernia is suspected but has been difficult to confirm on imaging studies, a TAPP approach may offer a better view to determine the presence and location of the hernia. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults", section on 'Identifying occult hernia'.)
TECHNIQUES FOR REPAIR
Extraperitoneal exposure and dissection — The totally extraperitoneal (TEP) hernia repair avoids the peritoneal cavity by developing a plane of dissection in the preperitoneal space. The anatomy of the preperitoneal space and the location of the hernia defects are illustrated in the figure (figure 1). The TEP approach allows access to both groin regions and provides exposure of the inferior epigastric vessels, femoral vessels, pubic tubercle, Cooper's ligament, and spermatic cord.
Direct entry into the rectus sheath is via an incision just off the midline with blunt dissection to the linea semicircularis (figure 1). The anatomic landmarks for entry into the preperitoneal space are the median umbilical ligament and the hernia defect. The preperitoneal tissue is entered by establishing a plane between the posterior surface of the rectus muscle and the posterior rectus sheath and peritoneum (figure 2).
To dissect the preperitoneal space and obtain exposure:
●Make an infraumbilical incision contralateral to the hernia, which increases the distance between the incision and the hernia, and incise the anterior rectus sheath transversely. Retract the rectus muscle laterally to allow a 10 mm blunt trocar to be placed (figure 3) through which a dissector can be used to develop the preperitoneal space under direct vision using an angled laparoscope (figure 4). Alternatively, a balloon dissector can be used to expand this potential space (figure 5).
●Bluntly dissect the preperitoneal space in the avascular plane between the peritoneum and the transversalis fascia. Avoid the use of electrocautery during the dissection, as this can lead to nerve injury .
●Identify the course of the epigastric artery and vein, and try to maintain their position anteriorly against the abdominal wall. Occasionally, the balloon dissector may develop the wrong plane and will dissect the epigastric vessels from the abdominal wall, which can make the remainder of the procedure more challenging.
●Once the preperitoneal space is dissected below the arcuate line, place two additional 5 mm trocars in the midline under direct vision (figure 3). Position one of these approximately 5 cm superior to the pubic symphysis. Place the other cannula midway between the umbilicus and the pubic symphysis. Some surgeons prefer to place these working cannulas lateral to the 10 mm umbilical trocar, contralateral to the hernia. Once the preperitoneal space is developed, insufflate the space through the 10 mm camera port.
●The iliopubic tract (inguinal ligament) is not as well seen with a TEP approach, but can be felt at the lower border of the internal inguinal ring. Direct hernia sacs often reduce spontaneously during the course of dissection. Indirect sacs are more difficult to manage and can be quite adherent to the cord structures. To identify an indirect sac, trace the epigastric vessels toward their origin to identify the spermatic cord as it enters the internal ring (figure 6). Minimize dissection in the area of Cooper's ligament to avoid disrupting the venous circle of Bendavid, a venous network fixed to the abdominal wall in the subinguinal space, which can produce troublesome bleeding . Avoid excessive dissection in the region of the femoral canal, which can be identified by tracing Cooper's ligament laterally. Lymph nodes in the femoral canal can produce bleeding, and excessive dissection can lead to the development of a femoral hernia.
●Take care in dissecting an indirect hernia sac to ensure the vas deferens and the testicular blood vessels are not injured. Oftentimes, a cord lipoma will also be removed during this process. Once a small (<1.5 cm) sac is mobilized, it should be returned back to the peritoneal cavity (figure 7). Larger indirect (>3 cm) sacs that are difficult to dissect and reduce may need to be carefully divided just distal to the internal ring, leaving the distal sac in situ within the inguinal canal.
Transabdominal exposure and dissection — As with most laparoscopic procedures, the peritoneal cavity is entered during transabdominal preperitoneal (TAPP) hernia repair. The major advantage of the posterior approach to groin hernias is that all three hernia defects (direct, indirect, and femoral) are well-visualized and in close proximity to each other, allowing easy repair of any type of groin hernia.
To obtain exposure and dissect the preperitoneal space:
●Access the peritoneal cavity using standard techniques (eg, Hasson, Veress needle) at the umbilicus using a 10 mm cannula. Once access to the peritoneal cavity has been established, insufflate the abdomen and place two additional cannulas (5 mm) bilaterally in a horizontal plane with the umbilicus (figure 8). Access techniques for laparoscopic surgery are discussed in detail elsewhere. (See "Abdominal access techniques used in laparoscopic surgery".)
●Identify the median and medial umbilical ligaments, bladder, inferior epigastric vessels, vas deferens, spermatic cord, iliac vessels, and hernia defects (figure 1). Incise the peritoneum beginning at the lateral edge of the median umbilical ligament at least 4 cm above the hernia defect and extending 8 to 10 cm laterally. For patients with bilateral hernias, a single transverse peritoneal incision extending from one anterior superior iliac spine to another on the opposite side can be used rather than two separate peritoneal incisions. It is important to make the incision sufficiently above the hernia defect to allow dissection of 2 to 3 cm of normal fascia to provide sufficient mesh overlap after mesh placement.
●Develop the peritoneal flap in the avascular plane between the peritoneum and the transversalis fascia. Mobilize the peritoneal flap to expose the pubic symphysis, Cooper's ligament, iliopubic tract, cord structures, inferior epigastric vessels, and hernia spaces. Be careful to identify and avoid injury to the femoral branch of the genitofemoral and lateral femoral cutaneous nerves.
●Gently reduce a direct inguinal hernia from the preperitoneal fat using gentle traction. Indirect sacs should be mobilized from the cord structures and reduced into the peritoneal cavity (figure 9). A larger hernia sac that is difficult to mobilize from the cord without undue trauma to the vas deferens or vasculature to the testicle can be divided just distal to the internal ring, leaving the distal sac in situ within the inguinal canal.
Mesh placement and fixation — Although some surgeons support nonfixation of mesh, we suggest mesh fixation rather than nonfixation for laparoscopic hernia repair to avoid the complications associated with mesh migration and mesh shrinkage.
Stapling/tacking injuries to the nerves are the most common source of postoperative neuralgia following laparoscopic hernia repair. This complication should be suspected if severe groin pain develops in the recovery room, and should prompt the surgeon to return to the operating room to remove the offending tack. Inadvertently entrapping or otherwise injuring a nerve can also lead to chronic pain.
Although the nerves are essentially never seen during laparoscopic hernia repair except in the thinnest of patients, nerve injuries can be prevented by avoiding the known course of the nerves relative to points of mesh fixation. Some surgeons feel that not fixing the mesh is the best way to avoid injury, and also avoids the costs of the staple and reduces operative time [28,29]. A systematic review of six randomized trials involving 772 patients compared mesh fixation with nonfixation . An advantage was found for nonfixation in terms of length of hospital stay (mean difference [MD] -0.37, 95% CI -0.57 to -0.17 days), operative time ([MD] -4.19, 95% CI -7.77 to -0.61 days), and cost. However, there was no significant difference in hernia recurrence, time to return to normal activities, seroma, and postoperative pain. A later trial found similar outcomes, but worse pain scores for staple fixation, but no differences in analgesic requirements . Although nonfixation appears to be safe in the short term, serious long-term complications can occur related to migration of the nonfixed mesh, such as erosion of the mesh into adjacent organs. Thus, most surgeons continue to fix the mesh into place using staples, tacks, or fibrin glue, each of which appear to have similar outcomes with regard to the risk of recurrent hernia [32-35].
Metallic fixation devices (eg, Protak) provide greater fixation strength but can cause serious complications such as adhesion formation or tack erosion into hollow viscera . Other devices (eg, AbsorbaTack, Permasorb, or SorbaFix) are bioabsorbable, but provide less fixation strength over time. Compared with tacks, fibrin glue has been associated with less chronic groin pain when used to secure mesh during hernia repairs .
Mesh placement for unilateral inguinal hernia repair is performed in a similar fashion for TEP and TAPP. Bilateral repairs using a single piece of mesh can be performed much more easily with a TEP approach because a single, large space is created, whereas with TAPP, each space is separately created. To place and fix the mesh:
●Introduce a rolled up 15 X 10 cm piece of prosthetic mesh into the preperitoneal space through the 10 mm umbilical cannula once the dissection is completed and the hernia sac reduced.
●The landmarks for fixation of the mesh are the pubic tubercle, Cooper's ligament, posterior rectus sheath, and the transversalis fascia at least 2 cm above to the hernia defect.
●Position the mesh so that it completely covers the direct, indirect, and femoral hernia spaces (figure 10). Some surgeons slit the mesh longitudinally or vertically to accommodate the cord structures, however, we prefer to simply place the mesh over the cord.
●Do not tack or staple the mesh below the iliopubic tract lateral to the spermatic cord and the epigastric vessels to minimize the chance of damaging nerves and vascular structures . This area contains the "triangle of pain," which contains the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve, and the adjacent "triangle of doom," which contains the external iliac artery and vein defined medially by the vas deferens and laterally by the spermatic vessels.
Closure — Following the fixation of the mesh, the inferior peritoneal flap that is developed during TAPP repair should be positioned over the mesh to isolate it from the peritoneal cavity using running suture, staples, tacks, or a biological sealant. Avoid gaps when closing the peritoneum to minimize the likelihood of future small bowel herniation and obstruction.
Once the hernia repair is completed, a long-acting local anesthetic (eg, bupivacaine) can be sprayed onto the preperitoneal space and surfaces for preemptive analgesia.
The ports are removed and the preperitoneal space (TEP) or abdominal cavity (TAPP) is decompressed. The fascia at the 10 mm umbilical cannula should be sutured to reduce the chance for future incisional hernia. We use absorbable subcuticular sutures to close the skin incisions.
TECHNIQUES FOR RECURRENT HERNIA REPAIR — When a laparoscopic repair is chosen for recurrent inguinal hernia repair, either the TEP or TAPP repair can be used, but we prefer the TEP repair when possible. The technical details of TEP and TAPP hernia repair are discussed in detail elsewhere. Several technical points for laparoscopic repair of a recurrent inguinal hernia deserve mention and are discussed below. (See 'TEP repair' above and 'TAPP repair' above.)
●The hernia sac may be difficult to reduce into the preperitoneal space because it often adheres densely to the mesh from the prior anterior mesh repair, particularly prior mesh plug repairs. In this setting, divide the indirect sac and seal over its proximal end using an endo-loop (detachable polypectomy snare) or clips.
●Be prepared to manage pneumoperitoneum. Peritoneal tears are more common than during repairs of primary hernias because of the dense adherence of the mesh to the peritoneum. Conversion to a TAPP procedure may become necessary.
●Carefully examine the femoral space for the presence of a hernia during the dissection, since femoral hernia is more common with recurrent hernia than with primary repairs .
Re-do laparoscopic repairs — Dissection of the preperitoneal plane is often difficult after a previous posterior mesh repair. For that reason, an attempt at a repeat totally extraperitoneal (TEP) repair will often result in a peritoneal breach, forcing conversion to a transabdominal preperitoneal (TAPP) repair. For patients with prior lower midline or preperitoneal operations, either a laparoscopic TAPP repair with mesh or open preperitoneal repair with mesh will be easier to perform with the ultimate choice of procedure depending upon the expertise of the surgeon. In a patient who has not previously undergone an anterior repair, a tension-free anterior mesh repair would be preferred over a laparoscopic repair for a hernia recurrence after a prior laparoscopic repair.
POSTOPERATIVE CARE AND FOLLOW-UP — Most laparoscopic hernia repairs are performed on an outpatient basis with the patient returning home once recovered from anesthesia. If the patient develops severe groin pain in the recovery room, it may be a sign that a staple or tack has been inadvertently placed through a nerve, and should prompt the surgeon to return to the operating room to remove the staple or tack. Postoperative pain is usually well-controlled using nonsteroidal antiinflammatory agents (NSAIDS), if not contraindicated, with or without low dose narcotic agents. (See "Management of acute perioperative pain", section on 'Oral analgesics'.)
Patients should be counseled to expect bruising and swelling in the groin. Follow-up in the office should be scheduled for two weeks postoperatively, in the absence of other problems.
There are few high-quality data regarding the timing of return to work or strenuous activity following laparoscopic hernia repair. Recommendations are tempered by the patient's pain tolerance. Patients can generally return to work 48 hours after a laparoscopic hernia repair if they are not required to perform heavy lifting or straining. If the patient is doing well without complications, they may resume any heavy lifting, straining, or exercise two weeks after laparoscopic hernia repair.
COMPLICATIONS — Complications of laparoscopic inguinal and femoral hernia repair include wound or mesh infection, seroma or hematoma formation, urinary retention, chronic groin pain, and hernia recurrence. The same list of complications can also be seen after open repairs. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Morbidity and mortality' and "Overview of complications of inguinal and femoral hernia repair".)
A 2012 metaanalysis found that patients who underwent laparoscopic inguinal hernia repair were more likely to develop a recurrence than those who underwent open repairs (relative risk [RR] 2.06, 95% CI 1.26-3.37) . In subgroup analyses, totally extraperitoneal (TEP) (RR 3.72, 95% CI 1.66-8.35), but not transabdominal preperitoneal (TAPP) repair (RR 1.14, 95% CI 0.78-1.68), was associated with a higher recurrence rate compared with open repairs.
Laparoscopic inguinal hernia repair was also associated with more perioperative complications than open repairs (RR 1.22, 95% CI 1.04-1.42). In this case, TAPP (RR 1.47, 95% CI 1.18-1.84), but not TEP (RR 1.05, 95% CI 0.85-1.30), was associated with a higher complication rate than open repairs.
The risk of chronic groin pain (RR 0.66, 95% CI 0.50-0.87) and numbness (RR 0.27, 95% CI 0.12-0.58) were both lower in patients who underwent laparoscopic, as opposed to open, repairs.
The outcomes of inguinal and femoral hernia repair are further discussed in detail in another topic. (See "Overview of complications of inguinal and femoral hernia repair".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Basics topics (see "Patient education: Inguinal and femoral (groin) hernias (The Basics)")
SUMMARY AND RECOMMENDATIONS
●The two commonly used approaches for laparoscopic repair of groin hernia are the totally extraperitoneal hernia repair (TEP) and the transabdominal preperitoneal hernia repair (TAPP), which approach the hernia defect posteriorly. The drawback of the TAPP procedure is entry into the peritoneal cavity. The TEP procedure, developed to avoid the risks of entering the peritoneal cavity, is technically more challenging. (See 'Laparoscopic repair approaches' above.)
●Contraindications to a laparoscopic approach to inguinal and femoral hernia repair include prior surgery in the preperitoneal space, active infection, incarcerated hernia, large scrotal hernias, ascites, and for TAPP, inability to tolerate general anesthesia. (See 'Contraindications' above.)
●For most male patients, we suggest the totally extraperitoneal approach (TEP), provided the surgeon has sufficient experience with the technique (Grade 2C). For patients in whom the TEP technique is not appropriate (eg, large hernia, prior lower midline surgery) or fails due to inability to develop the preperitoneal space, conversion to a transabdominal preperitoneal (TAPP) approach can be performed. On occasion, conversion to an open surgical approach may be necessary. For most female patients, we suggest the TAPP approach (Grade 2C). (See 'Choice of procedure: TEP or TAPP?' above.)
●We suggest mesh fixation, rather than no fixation, for all laparoscopic hernia repairs (Grade 2C). Mesh fixation avoids complications associated with mesh migration and mesh shrinkage, although it can be associated with inadvertent injury if a tack or suture is placed into a nerve. (See 'Mesh placement and fixation' above.)
●Stapling/tacking injuries to the nerves are the most common source of postoperative neuralgia following laparoscopic hernia repair. This complication should be suspected if severe groin pain develops in the recovery room, and should prompt the surgeon to return to the operating room to remove the offending tack. Inadvertently entrapping or otherwise injuring a nerve can also lead to chronic pain. (See 'Mesh placement and fixation' above.)
●Complications after laparoscopic inguinal/femoral hernia repairs are similar to those commonly seen after open repairs. The overall rates of hernia recurrence and perioperative complications are higher with laparoscopic repairs than open repairs. Compared with TAPP, TEP is associated with a higher recurrence rate but a lower complication rate. Both laparoscopic techniques are associated with less chronic groin pain and numbness than open repairs. (See 'Complications' above.)
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