Controversies

Minimally Invasive Repair of Inguinal Hernia
Since the late 1980s, there has been a quiet revolution in the surgical repair of groin, or inguinal, hernias. Nowadays nearly all inguinal hernias are repaired using a small piece of mesh, or screen, which allows a durable repair without placing tension on the surrounding muscles, leading to less pain for the patient and very low rates of recurrence. The open mesh repair has become the standard by which all other inguinal hernia repairs are measured.

As minimally invasive, or laparoscopic, surgery has advanced over the past decade or so, techniques for laparoscopic repair of inguinal hernias have been developed, perfected, and studied. In the laparoscopic repair, mesh is placed inside the pelvis after the hernia has been reduced, rather than on the outside of the pelvis, as is done with the “open” technique. Instead of an incision in the groin, three small incisions, measuring ¼ inch or ½ inch, are made in the skin of the lower abdomen, and slender laparoscopic instruments are passed through these small cuts into the pelvic space. The mesh is rolled up and inserted through a small tube into the space once the hernia opening is cleared out and exposed, and the unrolled mesh is secured with special tacks to keep it in place, covering the defect and preventing future hernias from occurring. Since the mesh is placed on the inside, and since the incisions are small, patients experience measurably less pain after the laparoscopic techniques than after the more traditional mesh repair.

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Controversies
No one denies that the laparoscopic repair has the advantage of being less painful than the open repair, and few surgeons deny that the results are comparable between the two in terms of recurrence. However, several issues are debated whenever hernia surgeons discuss the different approaches.

Safety:

Complications can occur in either technique, but the complication profile for laparoscopic repair is somewhat more serious. In the open repair, injuries can occur to nerves, causing skin numbness, or in extreme cases, severe postoperative pain. Bruising and swelling can occur, and the spermatic cord is manipulated, possibly placing the testicle in jeopardy. In the laparoscopic technique, a deep space is entered (the pelvis) and organs in the pelvis can be injured. These include urinary bladder, intestine, large blood vessels, and major nerves. In experienced hands the laparoscopic technique is extremely safe and such injuries almost never occur, but entering the pelvic space can potentially expose the patient to these risks.

Another risk which can actually occur with either technique is the risk of infection. The mesh used is a foreign body, and if an infection were to occur, the mesh might have to be removed. Some surgeons consider this to be an argument against using mesh at all.

Anesthesia Considerations:

An open repair can be performed with the patient under sedation, using local anesthetic agents to block all the nerves involved in the surgical field. The sedative agents leave the system quite quickly, and have few if any side effects. With the laparoscopic technique, general anesthesia is always required.

Cost Considerations:

The time it takes to do a laparoscopic repair is usually somewhat longer than the time it takes to do an open inguinal hernia repair. Most operating rooms charge by time unit, making laparoscopic repair more costly on this basis. In addition, laparoscopic instruments are usually disposable, contributing considerably to an increase in cost of the laparoscopic procedure as compared to the open approach, where all instruments are sterilized and used again.

Return to Activity:

In both types of hernia repair, normal activity, including lifting, driving, stairs, strenuous exercise, can be resumed as soon as discomfort at the surgical site allows. Since there is no tension on the mesh in either type of surgery, physical activity need not be restricted.

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Minimally invasive repair of inguinal hernia is the preferred method in certain specific situations. The technique is excellent for bilateral repairs, as once the pelvis is entered both sides can be approached through the same three small incisions. It is also a useful option if the hernia is recurrent, since the surgeon is likely to encounter scar tissue in a previously repaired site, making the dissection in an “open” repair more difficult. In this situation, the laparoscopic technique allows the surgery to be done in a completely fresh field where tissues are not distorted by previous surgery.

As in any type of surgery, it is important for the patient to be informed of the various options available for inguinal hernia repair. Risks, benefits, and alternatives should be discussed with the surgeon, and the discussion should cover the surgeon’s experience in the different types of repair. For many patients, minimally invasive hernia repair will be the right choice.

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