It is an undisputed medical conclusion that the only curable treatment for inguinal hernia is surgery. However, often when patients go to the hospital for surgical treatment, they find that there are many surgical options to choose from, and doctors often recommend one surgical option, which may be the most suitable for the patient or may be the surgeon’s best. In this article, I will try to introduce the advantages and disadvantages of the different surgical procedures in an easy-to-understand manner, hoping to bring some help to patients in understanding and choosing.
The surgical procedures currently offered by mainstream hospitals generally include open surgery and laparoscopic surgery, and laparoscopic surgery is generally divided into laparoscopic high ligation of the hernia sac, transabdominal preperitoneal patch repair (TAPP) and complete extraperitoneal patch repair (TEP). The author will introduce the advantages and disadvantages of each procedure separately and briefly summarize them at the end.
(A) Open surgery: advantages and disadvantages of open inguinal hernia tension-free repair
The so-called open surgery, which is often referred to in clinical practice, generally refers to open inguinal hernia tension-free repair, and the classic procedure is Lichtenstein repair, i.e., flat-piece repair.
Advantages of Lichtenstein repair.
1. This procedure is currently the most popular internationally and operated by the largest number of surgeons. It is classic, simple, does not rely on laparoscopy, does not require general anesthesia, and is less influenced by the level of anesthesiologists and surgeons.
2. It has a low recurrence rate. According to reports, the average recurrence rate of meshless hernia repair in the United States is about 10%-15%, and the recurrence rate of meshless hernia repair in Europe is nearly 35%; the recurrence rate of Lichtenstein’s tension-free hernoplasty performed by hernia surgeons is less than 1%, and the recurrence rate of the procedure performed by non-hernia surgeons (such as residents and interns) is about 4% –much lower than the recurrence rate of meshless hernia repair.
3. It is more advantageous for inguinal hernias with large sacs, heavy adhesions, and more complex hernia.
4. Less surgical risk.
5. Lower cost, eliminating the need for laparoscopy and general anesthesia
Disadvantages of Lichtenstein repair.
1. more sutures, such as suturing to part of the nerve, with the possibility of postoperative residual chronic pain
2. this procedure only repairs the upper part of the pubococcygeal foramen separated by the inguinal ligament, i.e. the internal ring opening and the straight hernia triangle. However, the lower part of the pubic foramen separated by the inguinal ligament, i.e. the opening of the femoral canal, cannot be repaired by this procedure.
3. In general, patients can be discharged 1-3 days after surgery, but some patients will be discharged for a longer period of time because of slight discomfort and pulling sensation and slightly restricted activities, and some patients cannot participate in work and activities in time after discharge.
4. Some patients with heavy adhesion of hernia sac or large hernia sac that cannot be retracted need to open the hernia sac, and some patients will have intestinal adhesions after surgery.
(B) Laparoscopic high ligation of hernia sac
The advantages of laparoscopic high ligation of the hernia sac include
1. No patch is needed, which does not affect the development of children in their growth period
2. Only a high ligation is needed, the operation time is short, usually a few minutes, and is less affected by general anesthesia
3. laparoscopic aesthetics, minimal trauma during the operation and fast postoperative recovery
Disadvantages of laparoscopic hernia sac ligation.
It is easy to recur because no patch is placed.
(iii) Transabdominal pre-peritoneal patch repair (TAPP)
Advantages of transperitoneal anterior peritoneal patch repair (TAPP)
1. This procedure is suitable for many forms of inguinal hernias, such as femoral, straight, and hiatal hernias, and is more advantageous for the treatment of bilateral and recurrent hernias.
2. Aesthetically pleasing, the incision in the abdominal wall is only a few small holes and the scars are not obvious.
3. Fast recovery after surgery, you can get out of bed within 6 hours after surgery, and you can be discharged from hospital earlier than open surgery, and it basically does not affect your work and life after discharge.
4. The recurrence rate is low, and the chance of recurrence of hernia is 0.8%-2.6% after preperitoneal patch repair.
Disadvantages of transabdominal preperitoneal patch repair (TAPP).
1. the probability of intestinal adhesions is higher than that of open surgery due to the opening of the abdominal cavity and the cutting of the peritoneum.
2. There is a risk of general anesthesia and the risk of laparoscopic surgery itself, which is influenced by the level of the surgeon.
3. Higher charges.
(iv) Complete extraperitoneal patch repair (TEP)
The advantages of complete extraperitoneal patch repair (TEP) are
1. This surgical procedure is suitable for many forms of inguinal hernia, such as femoral, straight, and hiatal hernia, and is more advantageous for bilateral hernia.
2. The procedure is performed without entering the patient’s abdominal cavity and is less likely to cause intestinal adhesions
There are no significant differences between the two surgical approaches in terms of postoperative complications, length of hospital stay, and recurrence rates for laparoscopic repair of laparoscopic inguinal hernia surgery. Because the TEP approach does not enter the patient’s abdominal cavity, it also avoids the need for peritoneal sutures, the operative time is relatively shorter, and the extraperitoneal space heals easily and is less traumatic for the patient.
Disadvantages of complete extraperitoneal patch repair (TEP).
1. TAPP surgery is usually easier to learn with clear anatomy and with clear landmark structural science. In the early days of TEP surgery, it was more difficult to learn due to the unclear level of the anatomical surface, and it took more experienced physicians to master proficiency in this surgical approach.
If difficulties are encountered during the TEP procedure or if the puncture accidentally enters the patient’s abdominal cavity, it is necessary to convert to the TAPP procedure in a timely manner. Therefore, physicians who master TEP also generally need to master TAPP.
3. The same risks of laparoscopic surgery and general anesthesia exist.
4. Can only deal with the simpler cases with lesser adhesions or smaller hernia sacs
5. Higher fees.
Summary
Open surgery: suitable for most cases, especially for those with limited conditions (including medical level, laparoscopic equipment, etc.), large and complex hernia sacs, unsuitable for laparoscopic surgery (e.g. elderly or cardiopulmonary dysfunction, etc.), and limited economic conditions.
Laparoscopic high ligation of the hernia sac: for growing children
TAPP is indicated for the following conditions: more complex inguinal hernias in patients who are not candidates for TEP but need aesthetic appeal, combined femoral or bilateral hernias, etc.
TEP: is recommended for most inguinal hernias, especially in patients with aesthetic needs, combined femoral or bilateral hernias, etc.
Of course, the most important thing to consider is that, given that inguinal hernia repair is a relatively common and simple procedure, there is not much difference between the various procedures, and it is also important to consider which procedure the surgeon specializes in.