Laparoscopic inguinal and femoral hernia repair in adults
- George A Sarosi, Jr, MD
George A Sarosi, Jr, MD
- Robert H. Hux Professor
- Department of Surgery
- University of Florida College of Medicine
- Kfir Ben-David, MD, FACS
Kfir Ben-David, MD, FACS
- Vice Chairman of Surgery
- Chief of Gastroesophageal Surgery
- Mount Sinai Medical Center
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".)
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].
- Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc 1992; 2:53.
- Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009; 13:343.
- McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993; 7:26.
- Ferzli G, Sayad P, Huie F, et al. Endoscopic extraperitoneal herniorrhaphy. A 5-year experience. Surg Endosc 1998; 12:1311.
- Wake BL, McCormack K, Fraser C, et al. Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database Syst Rev 2005; :CD004703.
- Vader VL, Vogt DM, Zucker KA, et al. Adhesion formation in laparoscopic inguinal hernia repair. Surg Endosc 1997; 11:825.
- Escobar Dominguez JE, Gonzalez A, Donkor C. Robotic inguinal hernia repair. J Surg Oncol 2015; 112:310.
- Waite KE, Herman MA, Doyle PJ. Comparison of robotic versus laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. J Robot Surg 2016; 10:239.
- Higgins RM, Frelich MJ, Bosler ME, Gould JC. Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc 2017; 31:185.
- Mehaffey JH, Michaels AD, Mullen MG, et al. Adoption of robotics in a general surgery residency program: at what cost? J Surg Res 2017; 213:269.
- Rosenberg J, Bisgaard T, Kehlet H, et al. Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults. Dan Med Bull 2011; 58:C4243.
- Society for Surgery of the Alimentary Tract. SSAT patient care guidelines. Surgical repair of groin hernias. J Gastrointest Surg 2007; 11:1228.
- Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet 2003; 362:1561.
- McCormack K, Scott NW, Go PM, et al. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003; :CD001785.
- Nordin P, Zetterström H, Gunnarsson U, Nilsson E. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet 2003; 362:853.
- Scott NW, McCormack K, Graham P, et al. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev 2002; :CD002197.
- Bay-Nielsen M, Kehlet H, Strand L, et al. Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 2001; 358:1124.
- Sajid MS, Kalra L, Parampalli U, et al. A systematic review and meta-analysis evaluating the effectiveness of lightweight mesh against heavyweight mesh in influencing the incidence of chronic groin pain following laparoscopic inguinal hernia repair. Am J Surg 2013; 205:726.
- Bittner R, Arregui ME, Bisgaard T, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 2011; 25:2773.
- Koch A, Edwards A, Haapaniemi S, et al. Prospective evaluation of 6895 groin hernia repairs in women. Br J Surg 2005; 92:1553.
- Schrenk P, Woisetschläger R, Rieger R, Wayand W. Prospective randomized trial comparing postoperative pain and return to physical activity after transabdominal preperitoneal, total preperitoneal or Shouldice technique for inguinal hernia repair. Br J Surg 1996; 83:1563.
- McCormack K, Wake BL, Fraser C, et al. Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review. Hernia 2005; 9:109.
- Molinelli BM, Tagliavia A, Bernstein D. Total extraperitoneal preperitoneal laparoscopic hernia repair using spinal anesthesia. JSLS 2006; 10:341.
- Ismail M, Garg P. Laparoscopic inguinal total extraperitoneal hernia repair under spinal anesthesia without mesh fixation in 1,220 hernia repairs. Hernia 2009; 13:115.
- Sinha R, Gurwara AK, Gupta SC. Laparoscopic total extraperitoneal inguinal hernia repair under spinal anesthesia: a study of 480 patients. J Laparoendosc Adv Surg Tech A 2008; 18:673.
- Lau H, Wong C, Chu K, Patil NG. Endoscopic totally extraperitoneal inguinal hernioplasty under spinal anesthesia. J Laparoendosc Adv Surg Tech A 2005; 15:121.
- Chowbey PK, Sood J, Vashistha A, et al. Extraperitoneal endoscopic groin hernia repair under epidural anesthesia. Surg Laparosc Endosc Percutan Tech 2003; 13:185.
- Mahon D, Decadt B, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc 2003; 17:1386.
- Rattner DW. Commentary regarding Laparoscopic inguinal hernia repair. In: Atlas of Minimally Invasive Surgery, Jones DB, Maithel SK, Schneider BE, Hart B (Eds), Ciné-Med, Woodbury, CT 2006. p.545.
- Bendavid R. The space of Bogros and the deep inguinal venous circulation. Surg Gynecol Obstet 1992; 174:355.
- Kapiris S, Mavromatis T, Andrikopoulos S, et al. Laparoscopic transabdominal preperitoneal hernia repair (TAPP): stapling the mesh is not mandatory. J Laparoendosc Adv Surg Tech A 2009; 19:419.
- Dulucq JL, Wintringer P, Mahajna A. Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years. Surg Endosc 2009; 23:482.
- Teng YJ, Pan SM, Liu YL, et al. A meta-analysis of randomized controlled trials of fixation versus nonfixation of mesh in laparoscopic total extraperitoneal inguinal hernia repair. Surg Endosc 2011; 25:2849.
- Chan MS, Teoh AY, Chan KW, et al. Randomized double-blinded prospective trial of fibrin sealant spray versus mechanical stapling in laparoscopic total extraperitoneal hernioplasty. Ann Surg 2014; 259:432.
- Sajid MS, Ladwa N, Kalra L, et al. A meta-analysis examining the use of tacker mesh fixation versus glue mesh fixation in laparoscopic inguinal hernia repair. Am J Surg 2013; 206:103.
- Hamouda A, Kennedy J, Grant N, et al. Mesh erosion into the urinary bladder following laparoscopic inguinal hernia repair; is this the tip of the iceberg? Hernia 2010; 14:317.
- Goswami R, Babor M, Ojo A. Mesh erosion into caecum following laparoscopic repair of inguinal hernia (TAPP): a case report and literature review. J Laparoendosc Adv Surg Tech A 2007; 17:669.
- Balakrishnan S, Singhal T, Samdani T, et al. Laparoscopic inguinal hernia repair: over a thousand convincing reasons to go on. Hernia 2008; 12:493.
- Reynvoet E, Berrevoet F. Pros and cons of tacking in laparoscopic hernia repair. Surg Technol Int 2014; 25:136.
- Shah NS, Fullwood C, Siriwardena AK, Sheen AJ. Mesh fixation at laparoscopic inguinal hernia repair: a meta-analysis comparing tissue glue and tack fixation. World J Surg 2014; 38:2558.
- Mikkelsen T, Bay-Nielsen M, Kehlet H. Risk of femoral hernia after inguinal herniorrhaphy. Br J Surg 2002; 89:486.
- O'Reilly EA, Burke JP, O'Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg 2012; 255:846.
- ANATOMIC CONSIDERATIONS
- Laparoscopic repair approaches
- - TEP repair
- - TAPP repair
- INDICATIONS FOR LAPAROSCOPIC REPAIR
- PREOPERATIVE EVALUATION AND PREPARATION
- Mesh for laparoscopic repair
- Patient positioning
- CHOICE OF PROCEDURE: TEP OR TAPP?
- TECHNIQUES FOR REPAIR
- Extraperitoneal exposure and dissection
- Transabdominal exposure and dissection
- Mesh placement and fixation
- TECHNIQUES FOR RECURRENT HERNIA REPAIR
- Re-do laparoscopic repairs
- POSTOPERATIVE CARE AND FOLLOW-UP
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS