Laparoscopic surgery is a minimally invasive procedure, but when this technique is used in the treatment of inguinal hernia, its “minimally invasive” nature has been controversial and challenged. In the traditional view, laparoscopic inguinal hernia repair (which has a long learning curve, requires general anesthesia and laparoscopic equipment, and is more expensive), while open surgery is simple, the incision itself is small, and can be performed under local anesthesia, so it is natural to ask the question: “Why should laparoscopic inguinal hernia repair be performed? This article will answer this question from the following aspects.
I. Whether LIHR is a safe and effective surgery
In order to perform LIHR, it must first be proven to be a safe and effective surgical procedure. The level of recurrence and complication rates is one of the most important indicators for evaluating the efficacy of LIHR. In the last 20 years, a large body of literature has studied LIHR in comparison with open hernia repair, with inconsistent results, but almost all reports have one thing in common: both in LIHR and open surgery, recurrence and complications occur mostly in early cases, showing that the efficacy of the procedure depends more on the experience of the operator than on the procedure itself. in 2000 and 2003, the Cochrane Medical Database published systematic evaluations and Meta-analyses of LIHR twice, and the results are authoritative.
(1) The recurrence rate of LIHR is the same as that of open tension-free repair and lower than that of conventional suture repair;
(2) LIHR had higher intra-abdominal complications than open surgery, lower complications such as incision and patch infection than open surgery, and the same overall complication rate for both. These evidences prove that LIHR can completely achieve the same efficacy as open tension-free repair, and provide a clinical basis for carrying out LIHR.
II. Why preperitoneal repair surgery should be performed
In order to answer the question “Why laparoscopic inguinal hernia repair?” we must first understand “why should we perform preperitoneal hernia repair surgery”, because LIHR is a kind of “preperitoneal repair” surgery. There are dozens of procedures for the treatment of inguinal hernias, which can be divided into three basic approaches according to their repair of different weak points.
(1) strengthening of the posterior wall of the inguinal canal, such as flat-piece repair (Lichtenstien et al.);
(2) repair targeting the hernia ring, such as mesh peg filling (Rutkow et al.);
(3) repair of the posterior wall of the reconstructed inguinal canal, such as preperitoneal repair (Stoppa et al.).
Theoretically, preperitoneal repair has a better rationale than the first two procedures due to.
(1) It is consistent with the etiology theory: weakness of the transversalis fascia is the main cause of hernia formation, and preperitoneal repair involves implanting a patch between the transversalis fascia and the peritoneum, which is equivalent to reconstructing a piece of the transversalis fascia;
(2) Anatomical structure: the patch covers the whole muscle pubic foramen, completely repairing the weak area of the inguinal region;
(3) Compliant with the mechanics: the patch is implanted posterior to the hernia defect, effectively cushioning the impact of intra-abdominal pressure;
(4) There is enough space in the preperitoneal space to allow implantation of a larger patch, increasing the insurance factor for recurrence prevention. Since the preperitoneal repair is the most reasonable procedure, it has been more and more widely used in clinical practice in recent years and has become an irreplaceable procedure among many tension-free repairs, which also provides a theoretical basis for carrying out LIHR.
III. Why laparoscopic technique is used for preperitoneal repair surgery
There are three methods of LIHR: transabdominal preperitoneal patch implantation (TAPP), total extraperitoneal patch implantation (TEP), and intraperitoneal patch implantation (IPOM), the first two of which are preperitoneal repair procedures and are the most commonly used procedures in LIHR. When a patient has an indication for preperitoneal repair, either open surgery or laparoscopic surgery can be chosen. The principles of repair and the level of repair are the same for both methods, and the choice of procedure depends mainly on the clinical experience of the surgeon. Compared with open preperitoneal repair, LIHR has some characteristics of its own that are worth considering when choosing.
(1) LIHR is a true “posterior approach” procedure, where the incision is made away from the patch repair area and there are no complications such as incision or patch infection;
(2) All operations are performed posteriorly to the transversus abdominis fascia and do not require incision of the transversus abdominis fascia;
(3) LIHR is operated under direct laparoscopic view and with magnified images, with clear anatomical landmarks, reducing the chance of vascular and nerve injury;
(4) It is more convenient to separate the anterior peritoneal space using laparoscopic instruments, and the patch is easier to spread, eliminating the need for special molding patches and reducing the cost of patches;
(5) The incision of LIHR is tiny, aesthetically pleasing, and the postoperative pain is mild. A study showed that 84% of patients who had undergone open and LIHR procedures successively preferred LIHR;
(6) LIHR allows patients to return to non-restrictive activities sooner after surgery;
(7) LIHR has some advantages in treating bilateral hernias and recurrent hernias, as it does not require additional incisions for bilateral hernias and avoids the anterior pathway for recurrent hernias, simplifying the operation;
(8) LIHR can detect the presence of “hidden hernia” on the contralateral side and provide timely treatment;
(9) LIHR can provide a special visual angle to observe the anatomy of the musculo-pubic foramen from the posterior side, which helps surgeons better understand the characteristics and operation points of the anterior peritoneal repair.
In summary, LIHR has both the characteristics of preperitoneal repair and some features that are not found in open preperitoneal surgery, which is why it is important to perform LIHR.
It is worth mentioning that IPOM, another type of LIHR, is not advocated for the treatment of primary hernias because the patch is implanted directly in the abdominal cavity and requires the use of an expensive anti-adhesion patch. However, in patients with repeated multiple recurrences, sometimes IPOM may be the only option to simply fix the patch in the abdominal cavity over the hernia defect, regardless of the altered abdominal wall tissue structure. The simplest way to cure the most complex inguinal hernia is one reason not to be overlooked when choosing LIHR.
IV. Is the learning curve of LIHR long?
Is the learning curve of LIHR really long? In fact, the learning curve of LIHR includes two stages of learning laparoscopic techniques and hernia repair techniques. With the popularization of laparoscopic surgery, most doctors have mastered laparoscopic operation techniques, and some complications caused by pneumoperitoneum and puncture that were reported in the early stage are very rare. We do not advocate the promotion of LIHR in hospitals without adequate laparoscopic resources, nor do we encourage surgeons without experience in laparoscopic surgery to perform LIHR directly, but for a surgeon who has fully mastered laparoscopic techniques, the time required to learn LIHR should be the same as that required to learn open preperitoneal repair.
The literature reports that the learning curve for LIHR is around 50 cases, which may be slightly higher than for flat sheet repair or mesh bolus repair, but this is related to the nature of preperitoneal repair, since the general surgeon is usually not very knowledgeable about the anatomy of the preperitoneal space, and a learning curve of at least 50 cases is also required to perform open preperitoneal repair (e.g., PHS, Kugel, etc.). In fact, the laparoscope is just an instrument and we are still doing hernia repair surgery. In the future, laparoscopic operation is a technique that every surgeon must master, as are techniques such as suturing and knotting in open surgery. When this technique is applied to the treatment of inguinal hernia, it is no longer laparoscopic experience that determines the outcome, but familiarity and knowledge of the anatomy of the preperitoneal space.
V. Is the cost of LIHR very high?
The high cost is another important factor affecting the performance of LIHR. Compared with open surgery, the increased cost of LIHR consists of three main parts: anesthesia, laparoscopic equipment and instruments, and hernia fixation materials.
LIHR usually requires general anesthesia; epidural anesthesia has been reported abroad, and some operators in China have started to apply this type of anesthesia. We suggest that general anesthesia should be chosen as much as possible in the initial stage of LIHR development, and later the feasibility of anesthesia for LIHR and the reduction of anesthesia costs can be gradually explored. Open surgery can be performed under local anesthesia, but local anesthesia is not the gold standard anesthesia for hernia surgery, and different anesthesia options are available for different procedures. LIHR lacks the option of local anesthesia compared to open surgery, but rejecting LIHR because of this reason is a very one-sided view.
Laparoscopic equipment and instruments are necessary for LIHR. in LIHR, there are no consumables other than patches, and the application of reusable laparoscopic instruments instead of disposable instruments for LIHR can reduce the cost of the procedure without affecting the outcome. LIHR can be carried out in hospitals with laparoscopic equipment, and existing resources can be fully utilized without adding additional costs.
In the early days of LIHR, surgeons mostly used hernia fixators or biologic glue to fix the patch. In recent years, a large amount of literature has demonstrated that for hernia defects smaller than 4 cm, the patch can be left unfixed when performing LIHR. For hernia defects larger than 4 cm, sutures can now be used to fix the patch, and with improved techniques, laparoscopic suturing and knotting is now a very convenient operation. Therefore, the majority of LIHR no longer require hernia fixation material, which greatly reduces the cost of LIHR surgery.
From the above analysis, the increased cost of LIHR in hospitals with laparoscopic resources is only the cost of anesthesia, and it would be a pity to abandon this procedure by unilaterally overestimating the cost of LIHR. In a cost-benefit analysis, Kaid et al. found that despite the higher cost of LIHR, the indirect cost savings due to the early return to normal activities and work outweighed the additional high cost of the procedure itself; et al. concluded in a cost-effect analysis that LIHR provides better outcomes due to faster recovery, less postoperative In a cost-effect analysis, et al. concluded that LIHR results in better quality of life adjusted years (QALYs) due to faster recovery, less pain, and more pronounced for patients with bilateral and cryptic hernias.
VI. How to properly understand the relationship between LIHR and open surgery
Since LIHR is a safe, effective and reasonable procedure, and the learning curve and cost are within the acceptable range, can it be an alternative to open surgery? The answer, of course, is no. It is a mistake to simply categorize LIHR as a “minimally invasive” surgery and oppose it to an “open” surgery. LIHR should be one of the many tension-free repair procedures, and the main purpose of LIHR is not to pursue the “minimally invasive” effect, but to perform “preperitoneal repair” of inguinal hernia using laparoscopic instruments. This procedure has a “posterior approach”, which is not available in open surgery. Therefore, LIHR and open surgery should be complementary or supplementary.
There are three main categories of people for whom LIHR is indicated.
(1) Patients with indications for preperitoneal repair, such as elderly patients with weak transverse abdominal fascia, patients with direct or compound hernias, and patients with factors of increased intra-abdominal pressure;
(2) Patients who need to resume physical activity and work as soon as possible;
(3) Patients with recurrent hernias and bilateral hernias. For patients with hiatus hernia who have good tissues, flat or mesh repair surgery under local anesthesia or spinal anesthesia can completely cure the hernia, and blindly choosing LIHR may cause “excessive” surgery. In addition, hospital conditions and the operator’s own laparoscopic skills and experience must be taken into account, otherwise unnecessary recurrences and complications may occur.
There are many different types of inguinal hernia repair, and there is no “gold standard” procedure; what is currently used in clinical practice is a reasonable procedure, the correct choice of which will provide the best clinical and health economic benefit. For the surgeon, mastering both the open and LIHR approaches is an additional weapon of choice.