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LAPAROSCOPIC INGUINAL HERNIA REPAIR

Where are we in

George Ferzli, MD, FACS


Professor of Surgery, SUNY

These are the questions


we have already
answered:

What are the indications for laparoscopic


inguinal hernia repair?
Recurrent hernia
Avoids scar tissue
Visualizes occult hernia

Bilateral hernia
Decreased pain
Earlier return to work
No difference in recurrence or complication

Obese / Athletic patients


Definitive diagnosis
Reduced infection in susceptible population
Gilmores groin

Patients with contralateral injury to vas deferens


Less chance to injure other vas

Are there contraindications to laparoscopic


inguinal hernia repair?
Contraindications
Patients for whom general anesthesia and
pneumoperitoneum are risks (cardiac, pulmonary
disease)

Relative Contraindications
Prior pre-peritoneal surgery (prostate, hernia, vascular,
kidney transplant)
Prior laparotomy
Ascites
Strangulated hernia
Giant scrotal hernia
Anticipated bleeding (patients on anti-coagulation)

How do recurrence rates for open and


laparoscopic hernia repair compare?
Reference

Year

Pts/R Hrns

Hernia Tech

RR

Bay-Nielson

2001

547

Lap
Licht
Muscle repair

1.6%
1.0%
2.7%

9,982
4,373
EU Hernia
Trialist Collab

2002

1,643
1,612

Lap
Open

2.2%
1.7%

Neumayer

2004

862

Lap
Open

10.1%
4.9%

Lap
Lap

<5%
>10%

834
Highly experienced
Less than 250

No difference in rate of recurrence between laparoscopic and open


procedures for primary hernia repair.

What is the role of laparoscopy for


treating recurrent inguinal hernia?
Less recurrence
Less pain
Earlier return to activity
No missed hernia

What percentage of a general surgeons


practice are recurrent hernias?

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% (1.7-2.3).

% 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 - 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%

Re-recurrence after TAPP for recurrence


(national and large studies)
Reference

Pts/Hrns

PT

RT (no. Pts or Hrns)

RR (%)

Haapaniemi
2001
Licht. (685) 1.46
Plug (276)
2.54
Other Mesh (574)
Non-mesh (483)

NA/2,688

Ant.

TAPP, TEP (670)

1.79

Bay-Nielson
2001
TEP (78)
1.3
Muscle (645) 6.7
Licht. (1,697) 3.2
Plug (212)
3.8
Plug and patch (358)
Other mesh (393)

NA/3,943

Var.

TAPP (560)

2.9

Wara

Year

3.83
4.35

3.6
5.6

2005
NA/6,689
Licht.
Lap. (1,361; 92% TAPP)
Licht. (4,633) 479
Bilateral recurrent hernia
Licht.
Lap (498; 92% TAPP)
Licht. (172) 756

Bokeler

2008

Bisgaard
2008
Licht. (344)
Non-mesh (198)
Mesh (non-Licht.) (194)

Unilateral recurrent hernia


463

261

1,689/1,755

Ant.

TAPP

0.6

NA/1,124

Licht.
11.3

Lap. (388; 95% TAPP)

1.3

19.2
7.2

Pts, patients; Hrns, hernias; PT, primary technique; RT, recurrent technique; RR, recurrence rate; NA, not available;
Var., various; TAPP, trans-abdominal pre-peritoneal repair; TEP, totally extra-peritoneal repair; Licht., Lichtenstein
repair; Lap, laparoscopy

TEP for recurrent inguinal hernia


Reference

Year

Pts

RT

RRR

Bay-Nielson

2001

78
1,697
645

TEP
Licht
Muscle repair

1.3%
3.2%
6.7%

Kouhia

2009

49

TEP

0.0%

47

Licht

6.4%

Prospective randomized

Pts: patients; RT: recurrent technique; RRR: re-recurrence rate;


TEP: totally extra-peritoneal repair; Licht.: Lichtenstein repair

Pain score after TAPP for recurrent


inguinal hernia
Reference Year

Technique

No. of Patients Median VAS

Beets

1999

TAPP/GPRVS

42/37

2.2/2.9 (p = 0.05)

Mahon

2003

TAPP/Licht.

60/60

2.8/4.3 (p = 0.003)

Dedemadi 2006

TAPP/Licht.

24/32

1.0/2.0 (p = 0.001)

Eklund
2007
(p = 0.019)

TAPP/Licht.

73/74

125 mm/165 mm

Neumayer 2004 Lap./Lich.


Difference in VAS
Day of surgery 10.2 mm (favoring TAPP)
Two weeks after surgery
6.1 mm (favoring TAPP)
Three months after surgery
No difference
VAS, visual analog of pain score; TAPP, trans-abdominal pre-peritoneal repair;
GPRVS, giant prosthesis for reinforcement of visceral sac; Licht., Lichtenstein
repair; Lap, laparoscopy

Pain score after TEP for inguinal hernia


Reference Year

Technique

Bringman

2003

TEP/Licht/Mesh-plug 92/103/104

1/2/2 (p = 0.001)

Eklund

2007

TEP/Licht

675/706

105/175 (p = 0.001)

2009

Chronic Pain
TEP/Licht

47/49

4/13 (p = 0.02)

Kouhia

No. of Patients Median VAS

VAS: visual analog of pain score; TEP: totally extra-peritoneal repair;


Licht: Lichtenstein repairs

Return to regular activity after TAPP for


recurrent inguinal hernia
Reference Year

Technique

Median days to return to work / activity

Beets

1999

TAPP/GPRVS

13/23

(p = 0.03)

Mahon

2003

TAPP/Licht

11/42

(p < 0.001)

Neumayer

2004

Lap./Licht.

4/5

(adj. HR 1.2; 95% CI 1.1 - 1.3)

Dedemadi

2006

TAPP/Licht

14/20

(p = 0.001)

Eklund

2007

TAPP/Licht

8/16

(p = 0.001)

TAPP, trans-abdominal pre-peritoneal repair; GPRVS, giant prosthesis for reinforcement


of visceral sac; Licht., Lichtenstein repair; HR, hazard ratio; CI, confidence interval; Lap,
laparoscopy

Return to regular activity after TEP


inguinal hernia repair
Reference Year Technique

Median days to return to work /


activity

Bringman

2003

TEP/Licht/Mesh-plug 14/25/29 (p < 0.0001)

Eklund

2007

TEP/Licht

7/12

(p <0.001)

Kouhia

2009

TEP/Licht

15/18

(p = 0.05)

TEP, totally extra-peritoneal repair; Licht., Lichtenstein repair

No missed hernia after TAPP/TEP for


recurrent hernia
Crawford found an incidence of 8% occult femoral hernia at laparoscopic repair,
and Felix found 9% concurrent femoral hernia.
Felix 1996
Recurrent
Primary
n = 152 patients
Femoral
9%
4%
n = 173 recurrent hernias Pantaloon
25%
14%
Chans 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 Mikklesen etal).
Bisgaard 2008
Rate
n = 2,117 re-operations

Repair type

Femoral recur.

Re-recurrence

Endoscopic rep. n = 34
0.00%
Open repair
n = 161
TAPP allows full visualization of the floor and avoids missed concomitant
ipsilateral or contralateral hernias.

8.07%

No missed hernia (femoral hernias)


3,980 femoral hernia repairs from Swedish Hernia Register
1,490 men, 2,490 women
35.9% (n = 1,430) underwent emergency surgery versus 4.9% of
inguinal hernia repair
Bowel resection - 22.7% of emergent femoral repair versus 5.4%
of emergent inguinal repair
Women at higher risk than men (40.6% versus 28.1%)
Mortality 10 times greater versus elective repair
Dahlstrand et al. Ann Surg 2009

Questions remaining in 2009

1. What is the role of TAPP/TEP


after TAPP/TEP?

TAPP/TEP after Recurrence of TAPP/TEP


Hernia Repair
Study
Primary Repair
Recur. Repair Tech. Re-recurrence
Follow up
Knook 1999
Various Lap.
TAPP
0.0%
35 months
Review
(n = 34)
Three institutions
n = 34 patients
n = 34 recurrent hernias
TAPP is a reliable technique for repair of recurrent hernia prior endoscopic repair.
Liebl 2000
TAPP (n =44)
Review of
TEP (n = 2)
Prospective
Single institution series
n = 44 patients
n = 46 recurrent hernias

TAPP

0.0%

26 months

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 months
Retrospective
Two institutions TAPP (n=16)
n = 3,017 patients
n = 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/TEP after Recurrence of TAPP/TEP


Hernia Repair
Study

Primary Repair

Recur. Repair Tech.

Re-recurrence

Follow up

Keider 2002
TAPP / TEP
TAPP / TEP
0.0%
37 months
Review
(n = 3)
Single institution
n = 3 re-operations by laparoscopy after 7 re-recurrences after laparoscopy
Laparoscopic 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%
NA
Review
(n = 135)
Single institution
n = 135 recurrent hernias
TAPP can be performed for recurrent inguinal hernia after TAPP with low recurrence rate, but the learning
curve is high.
Bisgaard 2008
Laparoscopic
TAPP (+/- 95%) (n = 14)
7.1%
NA
Review of prospective (n = 100)
Lichtenstein (n = 73)
2.7%
Danish hernia registry Nonmesh (n = 8)
0.0%
n = 67,306 primary repairs
Mesh (non-Licht.) (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.

Laparoscopic Hernia Repair (TAPP)


Marienhospital Stuttgart IV / 93 XII / 05

results

TAPP after
prperit.mesh-rep.

n = 135*
op-time [median,min.]
morbidity
reop.-rate
rec.-rate
return to work [med,d]
age [median]
BMI [median]

75
8,1 %
2,2 %
0,74 %
17
59 [29-90]
25
*own recurrences n=73
from outside
n=62

TAPP after preperitoneal mesh repair


Results (n=135)

Marienhospital Stuttgart IV /
93 XII / 05

[learning curve]

(Prof)*

1-45(1-20)*
(6/93-12/98)

op-time [median,min.](Prof.)*
morbidity
reop.-rate
rec.-rate
return to work[med.,d]

82,5 (87,5)*
14%
2,2%
18

46-90(21-40)* 91-135(41-56)*
(12/98-02/02)
71 (85)*
8%
2,2%
17

(2/02-11/05)
77 (57,5)*
2%
2,2 %
2,2 %
17

2. Do we have an answer for


groin pain after hernia repair?

Nerves prone to injury at herniorraphy:


anterior and posterior

Groin pain incidence


Author

# of Pts

Pain

A. S. Poobalan 2001

226

30% > 3 mo

Morten Bay-Nielsen 2001

1166

28.7% > year

S. Kumar 2002

454

30% >21 mo

C. A. Courtney 2002

4062

> 3 mo

Marcello Picchio 2004

593

25% > 1 yr

A. M. Grant 2004

928

Jrg Kninger 2004

208

36% (Shouldice)
31% (Lichtenstein)
15% (TAPP)
> 52 mo

Ulf Frnneby 2006

2456

31% >24 to 36 mo

Sergio Alfieri 2006

973

9.7% > 6 mo

E. K. Aasvang 2006

210

34.3% >1year

Pain Severe

Outcome of Pain

3%

3%

> 2.5 yrs 71% have pain


Severe in 22%
Mild in 45%

6%>1 yr
9.7%>1 yr

2.1 %> 6 mo

1.8% > 5 yrs

Mild
4.1% > 1yr
Severe 0.5% > 1yr
Less pain
75.8%
Same pain 16.7%
More severe 7.5%
> 6.5 years

* Groin pain or discomfort lasting more than 3 months after groin hernia repair.
Intern. Assn. for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms.
Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain. 1986; 3 (suppl): 1226.

Quality of life
Author

Pts

Pain affects the quality of life

Morten Bay-Nielsen 2001

1166

16.6%

S Kumar 2002

454

18.1%

Jrg Kninger 2004

208

14% (Shouldice)
13% (Lichtenstein)
2.4% (TAPP)

Ulf Frnneby 2006

2456

6%

EK Aasvang 2006

210
Nb

24.8%
6% after 6.5 years

Sergio Alfieri 2006

973

11.3% to 14.2%

Causes and risk factors of groin pain


Anatomical
Variation
Mesh repair

Innervation symmetry - 40.6%


Normal distribution - 20.3%
Normal anatomic pattern - 56.3%
No clear correlation between use of mesh and chronic pain

Age

Studies disagree on correlation between older age and postherniorrhaphy pain

Pre-operative pain

Pain associated with hernia before repair is associated with


post-operative pain

BMI

No correlation found between elevated BMI and postoperative pain

Post-operative
complications

Postoperative complications linked to an increased risk for


long term pain

Recurrent hernia
Day case surgery

Recurrence associated with recurrent pain


The probability of developing chronic pain is 2.5 times
higher in day-case patients, controlling for age
Open repair strongly correlated with post-operative pain
compared to laparoscopic repair

Open versus
laparoscopic

Types of post-operative groin pain

Neuropathic

Perineural fibrosis
Neuroma
Nerve entrapment
Direct lesions due to stretching
contusion,electrical injury,
and partial or complete division

Nonneuropathic

Osteitis pubis
Stapalgia
Meshalgia

Visceral

Spermatic cord problems


Orchitis
Vas deferens issues

Non-surgical management
Non-operative attempts at pain resolution include:
Biofeedback

Medications

Physical therapy

Percutaneous treatment with local anesthetics, steroids,


phenol, alcohol, cryoprobes, radiofrequency destruction

Transcutaneous nerve stimulators

Surgical management:
mesh/staple removal
Surgical treatment for periosteal reaction or osteitis pubis consists of
removing suture materials, staples, bulky suture knots, and/or bulk
forming or rolled mesh material from the pubic tubercle area.

Causes, prevention, and surgical management of postherniorrhaphy neuropathic inguidynia:


Triple neurectomy with proximal end implantation. Amid PK. Hernia 2004; 8: 343349.

Surgical management: neurectomy


Author

# of Pts

Excellent
relief

Partial relief

Poor
result

Lyon 1942

83%

Magee 1945

100%

Starling 1987

30

83%

Cathy H Lee
2000

54

68%
II 78%
IH 83%
GF 50%

Amid PK 2004

225

80%

15%

5%

James A.
Madura 2005
Aasvang 2009

100

72%

25%

3%

21

62%

24%
(no change)

14%

10%
11%
17%
25%

Surgical management: mesh removal,


neurectomy and hernia repair
The laparoscopic approach:
Diagnostic
Definitive hernia repair in unaltered tissues
Anterior approach:
Removal of the offending foreign body
Appropriate nerve resection
21 pts Licht (n=12), McVay (n=1), plug / patch (n=2), Shouldice (n=1), Lap (n=6)
6 weeks F/U, 20/21 pts were significantly improved
(3 pts had persistent numbness in the ilioinguinal nerve distribution
but remained satisfied with the procedure.)
KellerJE,StefanidiisD,DolceCJ,IanittiDA,KercherKW,HenifordTB.Combinedopenand
laparoscopicapproachtochronicpainfollowingopeninguinalherniarepair.2008AmerSurg74:
695701

Surgical management:
prophylactic neurectomy
Author

# of Pts

Pain (Neurectomy vs
Non-neurectomy)

Paresthesia

Ravichandran
2000

20
bilateral

0% vs 5%

10% vs 0%

Marcello Picchio
2004

408
vs 405

Mild:
21% vs 18%
Moderate: 3% vs 4%
Severe:
3% vs 2%
p 0.55

Numbness 4% vs 6%

Numbness
6.28%
Sensory Loss 1.04%

DE Tsakayannis
2004

191

p 0.39
Loss of touch sensation
11% vs 4% p 0.002
Loss of pain sensation
9% vs 8% p 0.89

George W
Dittrick 2004

66
vs 24

6 mos.3% vs 26% (p
0.001)
1 yr 3% vs 25% (p 0.003)

18% vs. 4%
13% vs. 5%

(p 0.10)
(p 0.32)

Wilfred Lik-Man
Mui 2006

50
vs 50

8% vs 28.6% (p 0.008)

42 vs 42.9

(P 0.931)

Surgical management:
nerve identification
Nerves
not
IDed

UA*

MV**

RR

95%CI

RR

95%CI

0.9

0.23.4

NS

2.2

0.226.4

0.539

2.1

0.68.1

NS

12.4

1.3115.3

0.027

3.8

1.211.4

0.019

19.2

2.3157.7

0.006

Identification and preservation of nerves during open inguinal hernia repair


reduce chronic incapacitating groin pain.
Chronic pain at 6 months after surgery was zero in those patients in whom all 3
nerves were identified and preserved, compared with the 40% incidence when
these nerves were all divided, or 4.7% when not all nerves were identified.
* Univariate Analysis: Risk of Complaining of Pain at 6 Months According to Nerve Treatment
**Multivariate Analysis:Risk of Complaining of Pain at 6 Months According to Nerve Treatment
Influence of Preservation Versus Division of Ilioinguinal, Iliohypogastric, and Genital Nerves During Open Mesh
Herniorrhaphy Prospective Multicentric Study of Chronic Pain Sergio Alfieri, MD, Ann Surg April 2006; 243: 553558

3. What is the role of laparoscopy


in the complex inguinal hernia?
Scrotal hernia
Incarcerated
Strangulated hernia: in the setting of
peritonitis and bowel necrosis

TAPP

Marienhospital Stuttgart, 3 / 1993 12 / 2007

results
[Marienhospital Stuttgart Apr 93 Dez 07]
PH

PH (without preop.)

scrotal hernia

post. repair

n=13136

last 2000

n=807

n=162*

40

40

60

75

morbidity

2,8%

1,7%

4,4%

7,0%

reop.-rate

0,4%

0,3%

0,85%

3,8%

0,7%

0,1%

2,3%

0,6%

14

10

17

17

60 [17-97] 50 [17-100]

61(18-97)

59 [29-90]

25

25

25

op-time

[med.,min.]

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

[Median]

BMI [Median]

25

*eigene Rezidive: n=92

extern vorop: n=70

What Are the Recommendations for


Laparoscopic Management of Complex Hernias?
Complex
Hernia Type

Management Recommendations

Level of
Evidence
(Authors)

Scrotal
Incarcerated
Inguinal

TAPP and TEP can be used with good results


Reserved for highly experienced TAPP/TEP surgeons
TAPP may be used for acute or chronic incarceration
TAPP allows easy inspection of questionable bowel
TEP may be used for acute or chronic incarceration
Must convert to intra-abdominal port to inspect bowel

III
(Ferzli, Liebl,
Palanivelu)

IV
(Palanivelu,
Leibl, Rebuffat,
Ishihara,Legnan
i, Scierski)

III
(Ferzli, Tamme,
Saggar)

Reserved for highly experienced TAPP/TEP surgeons


Strangulated
Hernia with
Peritonitis

Laparoscopic (TAPP or TEP) repair of strangulated


hernia should be avoided in the setting of :
Frank peritonitis
Infected abdominal wall
Necrotic bowel

IV
(Liebl, Ishihara,
Ferzli)

Conclusions:
Laparoscopic inguinal hernia repair in
2009 is feasible for primary, bilateral and
recurrent hernias.
The main challenge remains the learning
curve.
A thorough knowledge of the anatomy is
of utmost importance.

References
1)

Mahon D, Decadt M, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal


preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc
2003;17:138690

2)

Feliu X, Jaurrieta E, Vinas X, et al. Recurrent inguinal hernia: a ten year review. J Laparoendosc Adv Surg
Tech A 2004;14:3627

3)

Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent inguinal hernia: randomized multicenter trial
comparing laparoscopic and Lichtenstein repair. Surg Endosc 2007;21:63440

4)

Sarli L, Iusco D, Sansebastiano G, et al. Simultaneous repair of bilateral inguinal hernias: a prospective
randomized study of open, tension-free versus laparoscopic approach. Surg Laparosc Endosc Percutan
Tech 2001;11:2627

5)

Bay-Nielson M, Kehlet H, Strand L, Malmstrom J, Andersen FH, Wara P, Juul P, Callesen T. Quality
assessment of 26 304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet (2001) 358:
1124-1128

6)

EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh, meta-analysis of
randomized controlled trials. Ann Surg 2002;235:32232

7)

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

8)

Keller JE, Stefanidiis D, Dolce CJ, Ianitti DA, Kercher KW, Heniford TB. Combined open and laparoscopic
approach to chronic pain following open inguinal hernia repair. 2008 Amer Surg 74:695-701

References
9.

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

10. Bay-Nielson M, Kehlet H, Strand L, Malmstrom J, Andersen FH, Wara P, Juul P, Callesen T. Quality
assessment of 26 304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet (2001) 358: 11241128
11. Haapaniemi S, et al. Reoperation After Recurrent Groin Hernia Repair Ann Surg (2001), 234(1): 122126
12. Nilsson E, et al. Methods of repair and risk for reoperation in Swedish hernia surgery from 1992 to 1996. Brit J
Surg (1998), 85: 16861691
13. Amid PK, Shulman AG, Lichtenstein, IL. Opentension-free repair of inguinal hernias: the Lichtenstein
technique. Eur J Surg (1996) 162:447-53
14. Kark AE, Kurzer M, Belsham PA. Three thousand one hundred and seventy-five primary inguinal hernia
repairs; advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg (1998) 86:447-56
15. Beets GL, et al. Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia? A randomized
controlled trial. Surg Endosc (1999) 13: 323327
16. 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
17. 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
18. Eklund A, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and
Lichtenstein repair. Surg Endosc (2007) 21:634-40
19. Sandbichler P, et al. Laparoscopic repair of recurrent inguinal hernia. Amer J Surg (1996) 171:366-368

References
20) Felix EL, et al. Laparoscopic repair of recurrent hernia. Amer J Surg (1996) 172: 580-584
21) Jarhult J, et al. Laparoscopic treatment of recurrent inguinal hernias: Experience from 281 operations. Surg
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TAPP after TAPP Hernia re-recurrence


Reference

Year

Pts/R Hrns

PT

RT (no. Pts or Hrns)

RRR

Knook

1999

34/34

Lap.

TAPP (34)

0.0

Liebl

2000

44/46

TAPP

TAPP (44), TEP (2)

0.0

Bittner

2007

NA/135

TAPP

TAPP (135)

Bisgaard

2008

NA/100

Lap.

Lap (14; 95% TAPP)


Licht. (73)
Nonmesh (8) 0
Mesh (non-Licht.) (5)

Pts, patients; R Hrns, recurrent hernias; PT, primary technique; RT, recurrent technique;
RRR, rerecurrence rate; NA, not available; TAPP, trans-abdominal pre-peritoneal repair;
TEP, totally extraperitoneal repair; Licht., Lichtenstein repair; Lap, laparoscopy

0.74
7.1
2.7%
0

TAPP and TEP for incarcerated


femoral hernia
Incarcerated femoral hernia can be repaired by TAPP or TEP
but literature has been limited to case reports
TAPP for incarcerated femoral hernia
Watson (n = 1)
Yau (n = 8)
Comman (n = 1)
Rebuffat (n = 7)
TEP for incarcerated femoral hernia
Ferzli (n = 1)

Combined laparoscopic and open treatment

Recurrence after TAPP/TEP for Prior Hernia Repair Recurrence


Study

Primary Repair

Sandbilcher 1996

Anterior (muscle)
Prospective

Recur. Repair Tech.


TAPP

Re-recurrence

Follow up

0.5%

18 months

Single institution
n = 192 patients
n = 200 recurrent hernias
Laparoscopic repair can be applied to recurrent hernia with low morbidity and recurrence.
Felix 1996
Anterior (not sp.)
TAPP (n = 124)
0.58%
2 years
Review
TEP (n = 49)
Single institution
n = 152 patients
n = 173 recurrent hernias
Laparoscopy helps eliminate early failure resulting from missed hernia and intrinsic weakness.
Jarhult 1999
Anterior (not sp.)
Review
Single institution
n = 260 patients
n = 281 recurrent hernias

TAPP (n = 113)
TEP (n = 168)

11%
2%

49 months

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/TEP 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 patients
n = 93 recurrent hernias
n = 15 concomitant primary hernias
Laparoscopic recurrent hernia repair has lower morbidity vs. GPRVS but is difficult and has higher recurrence rate.
Memon 1999
Anterior (not sp.)
Laparosopic
27 months
Review
TAPP (n = 68)
Three institutions
TEP (n = 8)
n = 85 patients
IPOM (n = 19 )
n = 96 recurrent hernias
Unknown
(n = 1)
Laparoscopic recurrent hernia repair is safe, with acceptable recurrence and complication rates.
Haapaniemi 2001
2 years
Review of prospective
Swedish hernia registry
n = patient total not provided
n = 2,688 recurrent hernias

Anterior (not sp.)

2.94 %
0
10.53%
0

Lap. (TAPP and TEP)

1.79% (0.4)

(n = 670)
Lichtenstein (n = 685)
Plug (n = 276)
Other Mesh (n = 574)
Non-mesh (n = 483)

1.46% (0.4)
2.54% (0.9)
3.83% (0.9)
4.35% (1.0)

Study supports use of laparoscopy or anterior tension-free repair of recurrent hernia.

Recurrence after TAPP/TEP for Prior Hernia Repair Recurrence


Study

Primary Repair

Recur. Repair Techn.

Bay-Nielson 2001
Various
Review of prospective
Danish Hernia Registry
n = patient total not provided
n = 3,943 recurrent hernias

TAPP (n = 560)
TEP (n = 78)
Muscle repair (n = 645)
Lichtenstein (n = 1,697)
Plug (n = 212)
Plug and patch (n = 358)
Other mesh (n = 393)
Mesh repairs have lower reoperation rates than conventional open repair.

Re-recurrence

Follow up

2.9%
1.3%
6.7%
3.2%
3.8%
3.6%
5.6%

NA

Hawasli 2002
Anterior (not sp.) TAPP (screen and plug)
0.7%
5 years
Review
Single institution
n = 120 patients
n = 135 recurrent hernias
Recurrent 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
Review

TAPP (n = 115),
TEP (n = 15)

5.7%

37 months

Single institution
n = 130 patients
n = 150 recurrent hernia
Laparoscopic 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/TEP 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 months
Randomized
Lichtenstein (n = 60)
1.67%
Prospective
Single institution
n = 120 patients
n = 42 recurrent, 71 bilateral and 7 both bilateral and recurrent hernias
TAPP is beneficial, in terms of pain and return to work, for patients undergoing bilateral or recurrent hernia
repair.
Neumayer 2004
Randomized

Anterior (not sp)

Laparoscopic (10% TAPP) (n = 81) 10.0%


Lichtenstein (n = 78)
14.1%

2 years

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/TEP for Prior Hernia Repair Recurrence


Study

Primary Repair
Follow up

Recur. Repair Techn.

Re-recurrence

Dedemadi 2006

Anterior (not sp.)


3 years

TAPP (n = 24)

8.33%

Prospective
TEP (n = 26)
Randomized
Lichtenstein (n = 32)
n = 82 patients
n = 82 recurrent hernias
Laparoscopic hernia repair is the method of choice for recurrent inguinal hernia.

7.69%
15.63%

Eklund 2007

16.44%

Anterior (not sp.)


5 years

TAPP (n = 73)

Prospective
Lichtenstein (n = 74)
16.23%
Randomized
Multi-center
n = 147 patients
n = 147 recurrent hernias
Laparoscopic hernia repair has the short term advantage of less post-op pain and shorter sick leave.
Bokeler 2008

Anterior (not sp.)


NA

TAPP

0.60%

Retrospective
Single institution
n = 1,689 patients
n = 1,755 recurrent hernias
Laparoscopic 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/TEP 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 hernias
Laparoscopic 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
Prospective
Single institution
n = 61 patients
n = 65 recurrent hernias
Laparoscopic repair of recurrent inguinal hernia is safe and effective with low morbidity and recurrence and should be the gold standard for
these
hernias.
Kouhia
Prospective randomized

0.0%
6.4%

2009

49

47

Licht

Pts: patients; RT: recurrent technique; RRR: re-recurrence rate; TEP: totally extra-peritoneal repair; Licht.: Lichtenstein repair

TEP
5 years

Post-operative pain after TAPP/TEP for recurrent hernia


Study

Repair Technique

Median Visual Analog


of Pain Score (VAS)

TAPP (n= 42)


GPRVS (n = 37)

2.2
2.9

Beets 1999
1 week after surgery

Mahon 2003
24 hours after surgery

Neumayer 2004
Pain at day of surgery
Pain at two weeks after surgery
Pain at 3 month after surgery

p = 0.005

Median VAS
TAPP (n = 60)
Lichtenstein (n = 60)

2.8
4.3

p = 0.003

Difference in VAS
10.2 mm (favoring TAPP)
6.1mm (favoring TAPP)
No difference

Post-operative pain after TAPP/TEP for recurrent hernia


Study

Repair Technique

Median VAS

Day of Surgery

TAPP (n = 24)
Lichtenstein (n = 32)

4
5

p = 0.004

24 hrs after surgery

TAPP
Lichtenstein

1
4

p = 0.001

7 days after surgery

TAPP
Lichtenstein

1
2

p = 0.001

Analgesia use

Mean analgesia use

TAPP
Lichtenstein

1.9 days
3.2 days

Dedemadi 2006

Eklund 2007
Pain at 1 week after surgery

p = 0.001
p = 0.001

Median VAS
TAPP (n = 73)
Lichtenstein (n =74)

125 mm
165 mm

p = 0.019
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.

Return to work after TAPP/TEP for recurrent hernia


Study
Beets 1999

Median Return to Work / Daily Activities


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.

TAPP and TEP for scrotal hernia

Laparoscopic repair of the scrotal hernia is controversial and the literature on


the subject is scarce.
1996 - Ferzli described laparoscopy for scrotal hernia in 17 patients.
Utilized TEP. No recurrences. 1
1999 Liebl addressed subject of TAPP for scrotal hernia.
191 prospectively studied TAPP repairs for scrotal hernias.
Sac rarely transected.
Operative times slightly increased vs. normal TAPP repair.
Minor complication rate:
12% for scrotal vs. 5% for routine TAPP repair.
Most common complication: seroma.
Major complication rate: 1.6% for scrotal vs. 0.6% for routine repair.
Recurrence rate was 1%. 2
Palanivelu also presented a small series of patients using TAPP to repair
irreducible scrotal hernias with good results. 3