What is the recommended approach for laparoscopic hernioplasty (minimally invasive hernia repair)?

Laparoscopic Hernioplasty: Recommended Approach

Laparoscopic hernioplasty using either the totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) approach with synthetic mesh is the recommended standard for inguinal hernia repair, particularly for bilateral and recurrent hernias, offering reduced wound infection rates, lower postoperative pain, and comparable recurrence rates to open repair. 1, 2

Surgical Approach Selection

Primary Indication for Laparoscopic Approach

• Bilateral hernias: Laparoscopic repair is especially advantageous as it allows simultaneous repair of both sides through the same incisions, with operative times averaging 68 minutes and recurrence rates of only 0.2% 3, 4
• Recurrent hernias: The preperitoneal approach avoids previously scarred tissue from anterior repairs, making it safer and more effective 1, 4
• Occult contralateral hernias: Laparoscopy identifies contralateral hernias present in 11.2-50% of cases, preventing future operations 5, 6

Technique Selection: TEP vs TAPP

• TEP (Totally Extraperitoneal) is preferred when feasible as it avoids entering the peritoneal cavity, reducing risk of intra-abdominal complications 3, 4
• TAPP (Transabdominal Preperitoneal) is acceptable and may be easier in recurrent cases or when TEP proves technically difficult 5, 7
• Both approaches demonstrate comparable outcomes with low complication rates (5.7% minor complications) 3

Emergency/Complicated Hernia Considerations

Clean Surgical Field (No Strangulation)

• Prosthetic repair with synthetic mesh is strongly recommended (Grade 1A) for incarcerated hernias without signs of strangulation or need for bowel resection 5
• Laparoscopic approach is appropriate when there is no suspicion of bowel necrosis 1
• Hernioscopy can assess bowel viability after spontaneous reduction, decreasing hospital stay from 34 to 28 hours and preventing unnecessary laparotomies 5

Strangulated Hernias

• Open preperitoneal approach is preferable when strangulation is suspected or bowel resection may be needed 1
• Emergency repair is mandatory to prevent bowel necrosis, as delayed diagnosis beyond 24 hours significantly increases mortality 2
• Laparoscopic approach is contraindicated when bowel resection is anticipated or active strangulation with bowel compromise exists 1

Mesh Selection and Placement

• Synthetic mesh is the standard in clean surgical fields, associated with significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk 5
• Mesh must provide adequate coverage of the myopectineal orifice; inadequate coverage is the primary cause of recurrence 3
• For complicated cases with bowel resection but no gross spillage, synthetic mesh can still be used safely 2

Anesthesia Considerations

• General anesthesia is typically required for laparoscopic approaches 1
• Local anesthesia is feasible for TEP approach in select patients, particularly those with contraindications to general anesthesia, using average 28cc lidocaine 8
• Local anesthesia is recommended for emergency open repair in absence of bowel gangrene 1, 2

Age-Related Considerations

• Patients ≥65 years are 4 times more likely to undergo open rather than laparoscopic repair, though this may reflect surgeon bias rather than optimal practice 9
• Age alone should not preclude laparoscopic approach if patient can tolerate general anesthesia 9
• Anticoagulant use increases likelihood of open approach 38-fold, requiring careful consideration 9

Outcomes and Advantages

Laparoscopic Benefits

• Significantly lower wound infection rates (P<0.018) compared to open repair in emergency settings 5
• Reduced postoperative pain and faster return to normal activities 1, 2
• No increase in recurrence rates compared to open repair (P<0.815) 5
• Shorter hospital stays in emergency cases using hernioscopy 5

Complication Monitoring

• Accidental peritoneal rupture occurs in 25.7% of TEP cases but does not cause intra-abdominal complications 4
• Transitory neuropathic pain in femoral cutaneous area occurs in 1.8% of patients 4
• Monitor for wound infection, chronic pain, recurrence, and testicular complications 1, 2

Critical Pitfalls to Avoid

• Never delay repair of strangulated hernias—this leads to bowel necrosis with increased morbidity and mortality 6, 2
• Ensure adequate mesh coverage of the entire myopectineal orifice; technical failures from inadequate coverage are the primary cause of recurrence 3
• Do not overlook contralateral hernias—examine the opposite side laparoscopically as occult hernias are present in up to 50% of cases 5, 6
• Avoid laparoscopic approach when bowel resection is anticipated or strangulation is suspected—convert to open approach 1