Where are we in
Bilateral hernia
Decreased pain
Earlier return to work
No difference in recurrence or complication
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)
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
Pts/Hrns
PT
RR (%)
Haapaniemi
2001
Licht. (685) 1.46
Plug (276)
2.54
Other Mesh (574)
Non-mesh (483)
NA/2,688
Ant.
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)
261
1,689/1,755
Ant.
TAPP
0.6
NA/1,124
Licht.
11.3
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
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
Technique
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
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
Technique
Beets
1999
TAPP/GPRVS
13/23
(p = 0.03)
Mahon
2003
TAPP/Licht
11/42
(p < 0.001)
Neumayer
2004
Lap./Licht.
4/5
Dedemadi
2006
TAPP/Licht
14/20
(p = 0.001)
Eklund
2007
TAPP/Licht
8/16
(p = 0.001)
Bringman
2003
Eklund
2007
TEP/Licht
7/12
(p <0.001)
Kouhia
2009
TEP/Licht
15/18
(p = 0.05)
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%
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.
Primary Repair
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.
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
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
# of Pts
Pain
A. S. Poobalan 2001
226
30% > 3 mo
1166
S. Kumar 2002
454
30% >21 mo
C. A. Courtney 2002
4062
> 3 mo
593
25% > 1 yr
A. M. Grant 2004
928
208
36% (Shouldice)
31% (Lichtenstein)
15% (TAPP)
> 52 mo
2456
31% >24 to 36 mo
973
9.7% > 6 mo
E. K. Aasvang 2006
210
34.3% >1year
Pain Severe
Outcome of Pain
3%
3%
6%>1 yr
9.7%>1 yr
2.1 %> 6 mo
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
1166
16.6%
S Kumar 2002
454
18.1%
208
14% (Shouldice)
13% (Lichtenstein)
2.4% (TAPP)
2456
6%
EK Aasvang 2006
210
Nb
24.8%
6% after 6.5 years
973
11.3% to 14.2%
Age
Pre-operative pain
BMI
Post-operative
complications
Recurrent hernia
Day case surgery
Open versus
laparoscopic
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
Non-surgical management
Non-operative attempts at pain resolution include:
Biofeedback
Medications
Physical therapy
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.
# 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:
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
TAPP
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
Management Recommendations
Level of
Evidence
(Authors)
Scrotal
Incarcerated
Inguinal
III
(Ferzli, Liebl,
Palanivelu)
IV
(Palanivelu,
Leibl, Rebuffat,
Ishihara,Legnan
i, Scierski)
III
(Ferzli, Tamme,
Saggar)
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.
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Eklund A, Rudberg A, Smedberg C, Enander LK, Leijonmark CE, Osterberg, J. Short-term results of a
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Dahlstrand, U, Wollert S, Nordin, P. Emergency femoral hernia repair a study based on a national
register . Ann Surg 249; 384-387
Year
Pts/R Hrns
PT
RRR
Knook
1999
34/34
Lap.
TAPP (34)
0.0
Liebl
2000
44/46
TAPP
0.0
Bittner
2007
NA/135
TAPP
TAPP (135)
Bisgaard
2008
NA/100
Lap.
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
Primary Repair
Sandbilcher 1996
Anterior (muscle)
Prospective
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)
Primary Repair
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
2.94 %
0
10.53%
0
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)
Primary Repair
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.
Primary Repair
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
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.
Primary Repair
Follow up
Re-recurrence
Dedemadi 2006
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%
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
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.
Primary Repair
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
Repair Technique
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
Repair Technique
Median VAS
Day of Surgery
TAPP (n = 24)
Lichtenstein (n = 32)
4
5
p = 0.004
TAPP
Lichtenstein
1
4
p = 0.001
TAPP
Lichtenstein
1
2
p = 0.001
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
23 days
Mahon 2003
TAPP
Neumayer 2004
Laparoscopy
Dedemadi 2006
TAPP
14 days (p = 0.001)
Lichtenstein 20 days
Eklund 2007
TAPP
8 days (p=0.001)
Lichtenstein 16 days