laparoscopic inguinal hernia repair where are we in 2009?

LAPAROSCOPIC INGUINAL HERNIA REPAIR

George Ferzli, MD, FACS

Professor of Surgery, SUNY

Where are we in

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– Gilmore’s 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 1.6% 9,982 Licht 1.0%

4,373 Muscle repair 2.7%

EU Hernia 2002 1,643 Lap 2.2%Trialist Collab 1,612 Open 1.7%

Neumayer 2004 862 Lap10.1%

834 Open 4.9%

“Highly experienced” Lap <5%“Less than 250” Lap >10%

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 surgeon’s 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 SeriesNilsson 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 Year Pts/Hrns PT RT (no. Pts or Hrns) RR (%)

Haapaniemi 2001 NA/2,688 Ant. TAPP, TEP (670) 1.79Licht. (685) 1.46Plug (276) 2.54Other Mesh (574) 3.83Non-mesh (483) 4.35

Bay-Nielson 2001 NA/3,943 Var. TAPP (560) 2.9TEP (78) 1.3Muscle (645) 6.7Licht. (1,697) 3.2Plug (212) 3.8Plug and patch (358) 3.6Other mesh (393) 5.6

Wara 2005 NA/6,689 Unilateral recurrent herniaLicht. Lap. (1,361; 92% TAPP) 4·63

Licht. (4,633) 4·79Bilateral recurrent hernia

Licht. Lap (498; 92% TAPP) 2·61Licht. (172) 7·56

Bokeler 2008 1,689/1,755 Ant. TAPP 0.6

Bisgaard 2008 NA/1,124 Licht. Lap. (388; 95% TAPP) 1.3Licht. (344)

11.3Non-mesh (198) 19.2Mesh (non-Licht.) (194) 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 TEP 1.3%

1,697 Licht 3.2%

645 Muscle repair 6.7%

Kouhia 2009 49 TEP 0.0%

Prospective randomized 47 Licht 6.4%

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

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

Pain score after TAPP for recurrent inguinal herniaReference Year Technique No. of Patients Median VASBeets 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 TAPP/Licht. 73/74 125 mm/165 mm

(p = 0.019)

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 No. of Patients Median VAS

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)

Chronic Pain

Kouhia 2009 TEP/Licht 47/49 4/13 (p = 0.02)

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

Licht: Lichtenstein repairs

Return to regular activity after TAPP for recurrent inguinal herniaReference 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

Crawford found an incidence of 8% occult femoral hernia at laparoscopic repair,

and Felix found 9% concurrent femoral hernia.Felix 1996 Recurrent Primaryn = 152 patients Femoral 9% 4%n = 173 recurrent hernias Pantaloon 25% 14%

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

concurrent Inguinal hernia

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

Chan believes prior inguinal hernia repair may precipitate a femoral hernia (15 x

higher according to Mikklesen etal).

Bisgaard 2008 Repair type Femoral recur. Re-recurrence Rate

n = 2,117 re-operations Endoscopic rep. n = 34 0.00% Open repair n = 1618.07%

TAPP allows full visualization of the floor and avoids missed concomitant ipsilateral or contralateral hernias.

No missed hernia after TAPP/TEP for recurrent hernia

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

1. What is the role of TAPP/TEP after TAPP/TEP?

Questions remaining in 2009

Study Primary Repair Recur. Repair Tech. Re-recurrence Follow upKnook 1999 Various Lap. TAPP 0.0% 35 monthsReview (n = 34)Three institutionsn = 34 patientsn = 34 recurrent herniasTAPP is a reliable technique for repair of recurrent hernia prior endoscopic repair.

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

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

Kapiris 2001 TAPP (n=17) TAPP (n=16) 0.62% (all repairs) 45 monthsRetrospectiveTwo institutions TAPP (n=16)n = 3,017 patientsn = 3,530 total hernias n = 388 recurrent hernias TAPP is difficult but safe and effective, with high patient satisfaction, in the hands of the welltrained 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 monthsReview (n = 3)Single institutionn = 3 re-operations by laparoscopy after 7 re-recurrences after laparoscopyLaparoscopic recurrent hernia repair is effective and superior to historical series. It should be the method of

choice if cost could bereduced.

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

curve is high.

Bisgaard 2008 Laparoscopic TAPP (+/- 95%) (n = 14) 7.1% NAReview 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.

TAPP/TEP after Recurrence of TAPP/TEP Hernia Repair

TAPP after präperit.mesh-rep.

n = 135*

op-time [median,min.] 75

morbidity 8,1 %

reop.-rate 2,2 %

rec.-rate 0,74 %

return to work [med,d] 17

age [median] 59 [29-90]

BMI [median] 25

Marienhospital Stuttgart IV / 93 – XII / 05 resultsresults

Laparoscopic Hernia Repair (TAPP)

*own recurrences n=73 from outside n=62

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

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

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

morbidity 14% 8 % 2%

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

rec.-rate - - 2,2 %

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

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

TAPP after preperitoneal mesh repair

Marienhospital Stuttgart IV / 93 – XII / 05

2. Do we have an answer for

groin pain after hernia repair?

Nerves prone to injury at herniorraphy: anterior and posterior

Author # of Pts Pain* Pain Severe Outcome of Pain

A. S. Poobalan 2001 226 30% > 3 mo

Morten Bay-Nielsen 2001 1166 28.7% > year 3%

S. Kumar 2002 454 30% >21 mo

C. A. Courtney 2002 4062 > 3 mo 3% > 2.5 yrs 71% have painSevere in 22% Mild in 45%

Marcello Picchio 2004 593 25% > 1 yr 6%>1 yr

A. M. Grant 2004 928 9.7%>1 yr 1.8% > 5 yrs

Jrg Kninger 2004 208 36% (Shouldice) 31% (Lichtenstein)15% (TAPP)> 52 mo

Ulf Fränneby 2006 2456 31% >24 to 36 mo

Sergio Alfieri 2006 973 9.7% > 6 mo 2.1 %> 6 mo Mild 4.1% > 1yr Severe 0.5% > 1yr

E. K. Aasvang 2006 210 34.3% >1year 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): 1–226.

Groin pain incidence

Quality of lifeAuthor 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 Fränneby 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 painAnatomical Variation

Innervation symmetry - 40.6%

Normal distribution - 20.3%

“Normal” anatomic pattern - 56.3%

Mesh repair No clear correlation between use of mesh and chronic pain

Age Studies disagree on correlation between older age and post-herniorrhaphy pain

Pre-operative pain Pain associated with hernia before repair is associated with post-operative pain

BMI No correlation found between elevated BMI and post-operative pain

Post-operative complications

Postoperative complications linked to an increased risk for long term pain

Recurrent hernia

Day case surgery

Open versus laparoscopic

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

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

Non-neuropathic

• 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 bulkforming 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: 343–349.

Surgical management: neurectomyAuthor # of Pts Excellent

reliefPartial relief Poor

result

Lyon 1942 6 83%

Magee 1945 5 100%

Starling 1987 30 83%

Cathy H Lee 2000

54 68%

II 78%

IH 83%

GF 50%

10%

11%

17%

25%

Amid PK 2004 225 80% 15% 5%

James A. Madura 2005

Aasvang 2009

100

21

72%

62%

25%

24%

(no change)

3%

14%

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.)

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

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 0.55p 0.55

Numbness 4% vs 6%

p 0.39

Loss of touch sensation

11% vs 4% p 0.002

Loss of pain sensation

9% vs 8% p 0.89

DE Tsakayannis 2004

191 0 Numbness 6.28%

Sensory Loss 1.04%

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% (p 0.10)

13% vs. 5% (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

• 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.

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: 553–558

Nerves not ID’ed

UA*

RR 95%CI P

MV**

RR 95%CI P

1 0.9 0.2–3.4 NS 2.2 0.2–26.4 0.539

2 2.1 0.6–8.1 NS 12.4 1.3–115.3 0.027

3 3.8 1.2–11.4 0.019 19.2 2.3–157.7 0.006

* 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

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

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

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

PH (without preop.)

last 2000

40

1,7%

0,3%

0,1%

10

50 [17-100]

25

PH

n=13136

40

2,8%

0,4%

0,7%

14

60 [17-97]

25

scrotal hernia

n=807

60

4,4%

0,85%

2,3%

17

61(18-97)

25

post. repair

n=162*

75

7,0%

3,8%

0,6%

17

59 [29-90]

25

n

op-time [med.,min.]

morbidity

reop.-rate

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

age [Median]

BMI [Median]

TAPP Marienhospital Stuttgart, 3 / 1993 – 12 / 2007

What Are the Recommendations for Laparoscopic Management of Complex Hernias?

Complex Hernia Type

Management Recommendations Level of Evidence

(Authors)

Scrotal •TAPP and TEP can be used with good results•Reserved for highly experienced TAPP/TEP surgeons

III(Ferzli, Liebl, Palanivelu)

Incarcerated Inguinal

•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

•Reserved for highly experienced TAPP/TEP surgeons

IV(Palanivelu,

Leibl, Rebuffat, Ishihara,Legnan

i, Scierski)

III(Ferzli, Tamme,

Saggar)

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;17:1386–90

2) Feliu X, Jaurrieta E, Vinas X, et al. Recurrent inguinal hernia: a ten year review. J Laparoendosc Adv Surg Tech A 2004;14:362–7

3) Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc 2007;21:634–40

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;11:262–7

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;235:322–32

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: 1124-1128

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

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: 1686–1691

13. Amid PK, Shulman AG, Lichtenstein, IL. Open“tension-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: 323–327

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

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 Laparosc, Endosc & Perc Tech (1999) 9(2):115-118

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

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

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

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

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

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

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

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

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

References

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

32) Kouhia S, Huttunen S, SilvastiS, Heiskanen J, Ahtola H, Uotila-Nieminen M, Kiviniemi V, Hakala T Lichtenstein hernioplasty versus totally extraperitoneal laparoscopic hernioplasty in treatment of recurrent inguinal hernia—A prospective randomized trial. 2009 Ann Surg 249: 384-387

33) Feliu X, Torres G, Vinas X, Martinez-Rodenas F, Fernandez-Sallent E, Pie J. Preperitoneal repair for recurrent inguinal hernia: laparoscopic and open approach. Hernia. (2004) 8(2): 113-6

34) Knook MTT, Weidema WF, Stassen LPS, van Steensel CJ. Endoscopic total extraperitoneal repair of primary and recurrent inguinal hernias. Surg Endosc (1999) 13: 507–511

35) Sayad P, Ferzli G. Laparoscopic preperitoneal repair of recurrent inguinal hernias. J Laparoendosc Adv Surg Tech A. (1999) 9(2): 127-30.

36) Aeberhard P, Klaiber C, Meyenberg A, Osterwalder A, Tschudi J. Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair - A multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC). Surg Endosc (1999) 13: 1115–1120

37) Staarink M, van Veen RN, Hop WC, Weidema WF. A 10-year follow-up study on endoscopic total extraperitoneal repair of primary and recurrent inguinal hernia. Surg Endosc. (2008) 22(8): 1803-6

38) van der Hem JA, Hamming JF, Meeuwis JD, Oostvogel HJ. Totally extraperitoneal endoscopic repair of recurrent inguinal hernia. Br J Surg. (2001) 88(6): 884-6

39) Ramshaw BJ, Tucker JG, Duncan TD, Heithold D, Garcha I, Mason EM, Wilson JP, Lucas GW. Technical considerations of the different approaches to laparoscopic herniorrhaphy: an analysis of 500 cases. Am Surg. (1996) 62(1): 69-72.

40) Felix EL, Michas CA, McKnight RL. Laparoscopic repair of recurrent hernias. Surg Endosc. (1995) 9(2): 135-8

References

41) Thill V, Simeons C, Smets D, Ngongang C, da Costa PM. Long-term results of a non-ramdomized prospective mono-centre study of 1000 laparoscopic totally extraperitoneal hernia repairs. Acta Chir Belg. (2008) 108(4): 405-8

42) Alani A, Duffy F, O’Dwyer PJ. Laparoscopic or open preperitoneal repair in the management of recurrent groin hernias. Hernia (2006) 10(2): 156-8

43) Bingener J, Dorman JP, Valdes G. Recurrence rate after laparoscopic repair of recurrent inguinal hernias: have we improved? Surg Endosc. (2003) 17(11): 1781-3

44) Feliu X, Jaurrieta E, Vinas X, Macarulla E, Abad JM, Fernandez-Sallent E. Recurrent inguinal hernia: a ten-year review. J Laparoendosc Adv Surg Tech A. (2004) 14(6): 362-7

45) Frankum CE, Ramshaw BJ, White J, Duncan TD, Wilson RA, Mason EM, Lucas G, Promes J. Laparoscopic repair of bilateral and recurrent hernias. Am Surg. (1999) Sep;65(9): 839-42

46) Barrat C, Surlin V, Bordea A, Champault G. Management of recurrent inguinal hernias: a prospective study of 163 cases. Hernia (2003) 7(3): 125-9

47) Bringman S, Ramel S, Heikkinen TJ, Englund T, Westman B, Anderberg B. Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: a prospective randomized controlled trial. Ann Surg 2003 Jan;237(1): 142-7

48) McCormack K, Scott NW, Go PM, Ross S, Grant AM; EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003;(1): CD001785

49) G. S. Ferzli, T. Kiel. The role of the endoscopic extraperitoneal approach in large inguinal scrotal hernias. Surg Endosc (1997) 11: 299–302

50) Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R. Scrotal hernias: a contraindication for an endoscopic procedure? Results of a single-institution experience in transabdominal preperitoneal repair. Surg Endosc (2000) 14: 289–292

References

51) Palanivelu C, Rangarajan M, John SJ. Modified technique of laparoscopic intraperitoneal hernioplasty for irreducible scrotal hernias (omentoceles): how to remove the hernial contents. Worl J Surg (2007) 31(9):1889-91

52) Leibl BJ, Schmedt CG, Kraft K, Kraft B, Bittner R. Laparoscopic transperitoneal hernia repair of incarcerated hernias: Is it feasible? Results of a prospective study. Surg Endosc (2001) 15: 1179–1183

53) Rebuffat C, Galli A, Scalambra MS, Balsamo F. Laparoscopic repair of strangulated hernias. Surg Endosc (2006) 20: 131–134

54) Ishihara T, Kubota K, Eda N, Ishibashi S, HaraguchiY. Laparoscopic approach to incarcerated inguinal hernia. Surg Endosc (1996) 10: 1111–1113

55) Legnani GL, Rasini M, Pastori S, Sarli D. Laparoscopic trans-peritoneal hernioplasty (TAPP) for the acute management of strangulated inguino-crural hernias: a report of nine cases. Hernia (2008) 12: 185-188

56) Scierski A. Laparoscopic operations of incarcerated inguinal and femoral hernias. Wiad Lek (2004) 57(5-6): 245-248

57) Ferzli G, Shapiro K, Chaudry G, Patel S. Laparoscopic extraperitoneal approach to acutely incarcerated inguinal hernia. Surg Endosc (2004) 18(2):228-31

58) Tamme C, Scheidbach H, Hampe C, Schneider C, Köckerling F. Totally extraperitoneal endoscopic inguinal hernia repair (TEP). Surg Endosc (2003) 17(2): 190-195

59) Aasvang EK, Kehlet H. The effect of mesh removal and selective neurectomy on persistent postherniotomy pain. Ann Surg 2009;249:327-34

60) Lau H, Patil N, Yuen W. Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males Surg Endosc (2006) 20: 76–81

References

61) Eklund A, Rudberg A, Smedberg C, Enander LK, Leijonmark CE, Osterberg, J. Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair Br J Surg 2006 Sep;93(9):1060-8

62) Dahlstrand, U, Wollert S, Nordin, P. Emergency femoral hernia repair a study based on a national register . Ann Surg 249; 384-387

References

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) 0.74

Bisgaard 2008 NA/100 Lap. Lap (14; 95% TAPP) 7.1Licht. (73) 2.7%Nonmesh (8) 0Mesh (non-Licht.) (5) 0

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

TAPP and TEP for incarcerated femoral herniaIncarcerated femoral hernia can be repaired by TAPP or TEP

but literature has been limited to case reports

TAPP for incarcerated femoral herniaWatson (n = 1) Yau (n = 8) Comman (n = 1) Rebuffat (n = 7)

TEP for incarcerated femoral herniaFerzli (n = 1)

Combined laparoscopic and open treatment

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

Sandbilcher 1996 Anterior (muscle) TAPP 0.5% 18 monthsProspective

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

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

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

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

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

Recurrence after TAPP/TEP for Prior Hernia Repair Recurrence

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

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

Memon 1999 Anterior (not sp.) Laparosopic27 monthsReview TAPP (n = 68) 2.94 %Three institutions TEP (n = 8) 0n = 85 patients IPOM (n = 19 ) 10.53%n = 96 recurrent hernias Unknown (n = 1) 0Laparoscopic recurrent hernia repair is safe, with acceptable recurrence and complication rates.

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

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


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

Bay-Nielson 2001 Various TAPP (n = 560) 2.9% NAReview of prospective TEP (n = 78) 1.3%Danish Hernia Registry Muscle repair (n = 645) 6.7%n = patient total not provided Lichtenstein (n = 1,697) 3.2%n = 3,943 recurrent hernias Plug (n = 212) 3.8%

Plug and patch (n = 358) 3.6% Other mesh (n = 393) 5.6%

Mesh repairs have lower reoperation rates than conventional open repair.

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

Keider 2002 Anterior TAPP (n = 115), 5.7% 37 months Review TEP (n = 15)

Single institutionn = 130 patientsn = 150 recurrent herniaLaparoscopic recurrent hernia repair is effective and superior to historical series – it should be the method of choice if cost could be reduced.


Study Primary Repair Recurrent Repair Technique Re-recurrence Follow up

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

Neumayer 2004 Anterior (not sp) Laparoscopic (10% TAPP) (n = 81) 10.0% 2 yearsRandomized Lichtenstein (n = 78) 14.1%

Prospective Multi-center n = 1,983 patients Experienced Laparoscopy (n >250) 3.6% n = 1,983 total hernias (n = 28)n = 159 recurrent hernias Experienced Lichtenstein (n >250) 17.2%(n = 64)Open mesh repair is superior to laparoscopy for primary hernia repair, but recurrence rates are similar forrecurrent hernia repair and for surgeons who are highly experienced.


Study Primary Repair Recur. Repair Techn. Re-recurrenceFollow up

Dedemadi 2006 Anterior (not sp.) TAPP (n = 24) 8.33%3 years

Prospective TEP (n = 26) 7.69%Randomized Lichtenstein (n = 32) 15.63%n = 82 patientsn = 82 recurrent herniasLaparoscopic hernia repair is the method of choice for recurrent inguinal hernia.

Eklund 2007 Anterior (not sp.) TAPP (n = 73) 16.44%5 years

Prospective Lichtenstein (n = 74) 16.23%RandomizedMulti-centern = 147 patients n = 147 recurrent herniasLaparoscopic hernia repair has the short term advantage of less post-op pain and shorter sick leave.

Bokeler 2008 Anterior (not sp.) TAPP 0.60%NA

RetrospectiveSingle institutionn = 1,689 patientsn = 1,755 recurrent herniasLaparoscopic hernia repair should be the “Gold standard” in the treatment of recurrent hernias after anterior repair, but it isessential to gain experience by using the laparoscopic technique for primary hernias.


Study Primary Repair Recurrent Repair Technique Re-recurrence Follow up

Bisgaard 2008 Lichtenstein TAPP (approx. 95%) (n = 388) 1.3% NAReview of prospective Lichtenstein (n = 344) 11.3%Danish hernia registry Nonmesh (n = 198) 19.2%n = patient total not provided Mesh (non-Lichtenstein) (n = 194) 7.2%n = 1,124 recurrent herniasLaparoscopic repair is recommended for reoperation of recurrence after primary open Lichtenstein repair. Trend favors laparoscopic repair of recurrence after non-mesh and non-Lichtenstein mesh primary repair. Laparoscopic repair of recurrence after laparoscopic primary repair shows no advantage in terms of re-recurrence. Tantia 2008 Anterior (not sp.) TAPP (n = 37), TEP (n = 28) 0.65% 36 monthsProspectiveSingle institutionn = 61 patientsn = 65 recurrent herniasLaparoscopic repair of recurrent inguinal hernia is safe and effective with low morbidity and recurrence and should be the gold standard for

thesehernias.

Kouhia 2009 49 TEP0.0%

Prospective randomized 47 Licht 5 years6.4%

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


Post-operative pain after TAPP/TEP for recurrent hernia

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

Beets 1999

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

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

Lichtenstein (n = 60) 4.3

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

Study Repair Technique Median VAS

Dedemadi 2006

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

24 hrs after surgery TAPP 1 p = 0.001 Lichtenstein 4

7 days after surgery TAPP 1 p = 0.001 Lichtenstein 2

Analgesia use Mean analgesia useTAPP 1.9 days p = 0.001Lichtenstein 3.2 days p = 0.001

Eklund 2007 Median VASPain at 1 week after surgery TAPP (n = 73) 125 mm p = 0.019 Lichtenstein (n =74) 165 mm p = 0.001 Median analgesia consumption decreased with TAPP vs LichtensteinThe short term advantage for patients who undergo laparoscopic repair is less postoperative pain.

Post-operative pain after TAPP/TEP for recurrent hernia

Return to work after TAPP/TEP for recurrent hernia

Study Median Return to Work / Daily Activities

Beets 1999 TAPP 13 days (p= 0.03)

GPRVS 23 days

Mahon 2003 TAPP 11 days (p = < 0.001)

Lichtenstein 42 days

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

Lichtenstein 5 days

Dedemadi 2006 TAPP 14 days (p = 0.001)


Eklund 2007 TAPP 8 days (p=0.001)


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

laparoscopic inguinal hernia repair where are we in 2009?

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