Spontaneous abdominal wall hernias in our community affect as high as 10% of the population. 80% of these are represented by inguinal hernias. The majority occur in active male patients. Repair is necessary to avoid future complications and restore normal physical function. With the widespread acceptance of “prosthetic meshes” and the “tension free concept”, inguinal hernia recurrence is now very uncommon and quoted as low as 0.1%.
The advantage of a pre-peritoneal (otherwise known as extra-peritoneal) hernia repair is that a large prosthetic mesh can be placed to cover all possible groin hernia defects (direct, indirect and femoral) using no tension. The intra-abdominal pressure keeps the mesh in place so therefore fixation with tacks or sutures is not always required. The inguinal canal and its contents are not opened and distorted; therefore far less pain is experienced.
With current advances in technology, a tension free pre-peritoneal mesh repair can now be performed through very small incisions using video assisted surgery or laparoscopic surgery. The 2 operations commonly performed are trans-abdominal pre-peritoneal mesh repair (TAPP) or total endoscopic extra-peritoneal mesh repair (TEP). I prefer to use a TEP when possible as you avoid entering the abdominal cavity and therefore the risks of visceral injury and mesh attaching and eroding into the bowel is much lower. I do perform a TAPP in select patients.
The procedure is performed as a day surgical case in hospital. A general anaesthetic is required to relax the rectus abdominus muscle. A small incision is made under the umbilicus and a 12mm port inserted in the pre-peritoneal space. The space is then filled with CO2 and two 5mm working ports inserted along the midline. A wide dissection of the pre-peritoneal space is performed under video assistance so as to position a large prosthetic mesh. Both sides can be repaired at the same time through the same small incisions.
After surgery patients can eat, drink and mobilize immediately. They can go home the same day even if a bilateral inguinal hernia was performed. Simple analgesics for pain relief are all that is required. Sometimes groin swelling can occur but tight briefs usually sort this out. Dressings can be removed in 5 days and there are no sutures to worry about. Return to work and normal physical activity is patient dependent, although we usually recommend light activity for the first week. After this time it is safe to proceed with most sporting and work activities.
Laparoscopic inguinal hernia repair is very safe in the hands of an experienced surgeon as the learning curve is very steep. Dr George Petrou has performed laparosopic inguinal hernia repair in over 400 patients who reside on the Mid North Coast NSW. He has never had a mortality, take-back for postoperative haemorrhage or infected prosthetic mesh after this procedure.
Soft tissue bruising of the groin skin, scrotom and penis can sometimes occur. This is temporarily unsightly but does not cause pain or delay recovery. Small post-operative fluid collections (seroma/ haematoma) can occur, but once again cause little discomfort and resorb spontaneously. Larger collections are uncommon but may require percutaneous needle aspiration to resolve. Post operative haemorrhage and mesh infection is rare. Prosthetic meshes offer the lowest risk of recurrence in inguinal hernia repair.
There are now many randomized controlled trials and systematic reviews (1) comparing open mesh repair with laparoscopic inguinal hernia repair (TAPP and/or TEP). There is no difference between laparoscopic and open mesh hernia repair with respect to recurrence rates. The advantages of a laparoscopic repair are significantly different in patients with bilateral inguinal hernia and recurrent inguinal hernia. These patients have far less pain, fewer complications and a quicker recovery if they have a laparoscopic mesh repair (TEP or TAPP). There is also emerging evidence that patients who have a unilateral laparoscopic inguinal hernia repair are less likely to suffer chronic pain, which can be a great hindrance to work, and quality of life after surgery (2).