REVIEW ARTICLE

Inguinal hernia repair: current surgical techniques

R. Bittner & J. Schwarz
Received: 2 November 2011 / Accepted: 6 November 2011 / Published online: 25 November 2011
# Springer-Verlag 2011
Abstract
Introduction Selection of an optimal surgical technique for
inguinal hernia repair, allowing safe performance and rapid
recovery without long-term complaints, may contribute
significantly to the reduction of national health care costs.
Methods An analysis of current literature regarding surgical
techniques, properties of modern meshes, operative com-
plications, recurrence rates, occurrence of chronic pain, and
quality of life after different surgical procedures was
made. Evidence-based comparisons of suture and mesh
techniques of open mesh and laparoscopic mesh repair
and of laparoscopic (TAPP) and endoscopic (TEP)
operation were made.
Results Recurrence rates after mesh implantation are
significantly lower than after suture repair. Recurrence rates
after flat open mesh repair are similar to those of
laparoscopic techniques, but there is a significantly faster
recovery after laparoscopy, and chronic pain is also present
less frequently. Both TAPP and TEP are acceptable
treatment options, but there is insufficient evidence to show
superiority of one technique over the other. Material-reduced
meshes seem to have advantages, at least during the early
postoperative period. Besides the properties of the mesh
implanted, the surgical technique applied and the skills of the
surgeon performing the operation are the most important
factors for achieving optimal and cost-efficient results.
Conclusion With regard to recovery and occurrence of
chronic pain, TAPP and TEP are superior to open mesh repair
in most cases. Greater efforts should be undertaken to make
laparoscopic repair easier, safer, and less expensive. If this can
be achieved, health care costs could ultimately be reduced.
Keywords Inguinal hernia
.
Laparoscopic hernia repair
.
Lichtenstein
.
Shouldice
.
Mesh implantation
Introduction
Inguinal hernia repair is the most common procedure in
general and visceral surgery worldwide. In Germany, more
than 200,000 operations are performed every year, and in
the USA, the number is close to 800,000. In Germany,
about 140,000 of the 200,000 repairs are performed in a
hospital setting (Statistisches Bundesamt Wiesbaden,
Fachserie 12, Reihe 6.2.1. 2006). According to the DRG
system, more than 322,000,000 is spent annually on
surgical treatment of hernias in the groin. Furthermore,
considering that (1) half of these patients are employed and
(2) each disabled employee leads to an average loss of 200
per day for employers, the resulting uncompensated costs
for the national economy will total about 14,000,000 per
day. In this respect, surgical treatment of inguinal hernia is
an important factor in calculating the costs of the German
health care system.
The first sound technique for the repair of inguinal
hernia was described by E. Bassini in 1887. Since that time,
more than 70 methods have been introduced. Today, only
three techniques remain which have been scientifically
validated and can be recommended for clinical application:
(1) the Shouldice technique, a form of suture repair, (2)
open anterior flat mesh repair according to Lichtenstein,
and (3) laparoscopic/endoscopic posterior flat mesh repair.
All three techniques show specific advantages and
disadvantages with respect to equipment, difficulty of
R. Bittner (*)
:
J. Schwarz
Department of General, Visceral and Vascular Surgery,
Herniacenter, EuromedClinic Frth,
Europaallee 1,
90763 Frth, Germany
e-mail: bittnerfamilie@web.de
Langenbecks Arch Surg (2012) 397:271282
DOI 10.1007/s00423-011-0875-7
performance, materials, complication and recurrence rates,
recovery times, and rates of acute and chronic pain.
Furthermore, in an era of increasing health care
expenditures, it is important to evaluate the financial burden
of these techniques attributable to the operation (direct
costs) and the recovery period (indirect costs) [1].
Graduation of external evidence
This review aims not only to reflect the personal experience
of one expert, but is supposed to provide an overview and
comparison of present techniques in inguinal hernia repair
based on currently available external evidence. For grading
of specific recommendations, the classification described
by the Oxford Centre for Evidence Based Medicine (2009)
was applied, consisting of five levels:
Levels of evidence (statements/conclusions)
1A Systematic review of randomized controlled studies
(RCTs) with consistent results from individual studies
1B RCTs (of good quality)
2A Systematic review of 2B studies (with consistent
results of individual studies)
2B Prospective comparative studies (or RCTs of poorer
quality)
2C Outcome studies (analysis of large registries,
population-based data, etc.)
3 Retrospective comparative studies, casecontrol studies
4 Case series (i.e., studies without control group)
5 Expert opinion, animal, or lab experiments
Grades of recommendation
Grade A Consistent level 1 studies; strict recommendations
(standard, Surgeons must do it.)
Grade B Consistent level 2 or 3 studies or extrapolations
from level 1 studies; less strict wording
(recommendation, Surgeons should do it.)
Grade C Level 4 studies or extrapolations from level 2 or
3 studies; vague wording (option, Surgeons
can do it.)
Grade D Level 5 evidence or troublingly inconsistent or
inconclusive studies at any level; no recommen-
dation at all, describe options
Suture repair (Shouldice)
Statements/conclusions and recommendations in this section
are based on the guidelines of the European Hernia Society [2].
The Shouldice hernia repair technique is the best non-
mesh repair method (level 1A). In 1994, in a randomized
controlled trial (RCT) comparing modified Bassini versus
Shouldice inguinal hernia repair, the recurrence rates after
3.3 years were 9.6% for the Bassini technique and only
1.7% for a Shouldice operation [3]. In 1996, in a systematic
review of controlled trials and a meta-analysis, Simons et
al. [4] found that the relative risk ratio (risk of developing a
recurrence) for pooled studies (n=2,500) was 0.62 (95%
confidence interval, 0.440.87) in favor of the Shouldice
technique. Thus, the Shouldice technique should be used
when a non-mesh repair is considered (grade A).
Earle Shouldice (18901965) published his method of
inguinal hernia repair in 1952 [5]. It was an evolution of
Bassini tissue repair. The details of the technique are similar
to those of Bassini repair, with a few key differences [1].
Detailed descriptions of the operative procedure have been
published by V. Schumpelick [6] and his coworkers as well
as recently by G. Arlt [7]. This approach quickly became
the Gold Standard for open repair [8], remaining so until
prosthetic mesh repairs became popular in the 1980s.
In Germany, until the middle of the 1990s, more than
55% of inguinal hernia repairs were done using the
Shouldice technique; today, this percentage has declined
to less than 20% (Statistisches Bundesamt 2006 Wiesbaden,
Fachserie 12, Reihe 6.2.1. 2006). There were two reasons
for this paradigm change: (1) in long-term studies, a high
recurrence rate of more than 10% was demonstrated
10 years after a Shouldice operation, even when performed
in expert clinics [9], and (2) several RCTs and meta-
analyses [1013] showed a significantly higher recurrence
rate after open suture repair (4.417%) compared to open
mesh repair (Lichtenstein; 11.4%). Factors found to be
significantly associated with recurrence were age greater
than 50 years, the existence of more than two similarly
affected relatives, smoking, and previous presence of a
recurrent hernia [9]. Furthermore, there is current discussion
of whether medial hernias with a large (>3 cm) gap
predispose to a recurrence. In view of the evidence reported
in this paper, even the strongest former protagonists
recommend a Shouldice repair in young males having a
lateral hernia with a small gap only. However, as shown by
the long-term results of the national Danish Hernia Database,
including only men between the ages of 18 and 30 years
with a primary repair of a primary indirect inguinal hernia,
cumulative incidence of reoperation because of recurrence at
5 years was 1.6% after Lichtenstein versus 3.9% after a
sutured repair [14], while overall reoperation rates were
almost threefold higher after a sutured repair (p=0.0003).
Open mesh repair (Lichtenstein)
Statements/conclusions and recommendations in this
section are based on the guidelines of the European
Hernia Society [2].
272 Langenbecks Arch Surg (2012) 397:271282
Operation techniques using mesh result in fewer
recurrences than techniques which do not use mesh
(level 1A). All adult male (>30 years) patients with a
symptomatic inguinal hernia should be operated on
using a mesh technique (grade A). The open
Lichtenstein and endoscopic inguinal hernia techniques
are recommended as the best evidence-based options for
the repair of a primary unilateral inguinal hernia,
providing the surgeon is sufficiently experienced in the
specific procedure (grade A). In Germany, until the beginning
of the 1990s, less than 1% of inguinal hernia repairs
were performed using an open mesh technique, whereas
today this percentage has increased to more than 35%
(Statistisches Bundesamt 2006 Wiesbaden, Fachserie 12,
Reihe 6.2.1. 2006).
The earliest plastic mesh used with any great success
was DACRON [15]. Hernias have been fixed with this
product since 1954 [1]. Usher and colleagues introduced
polypropylene mesh as a prosthetic for hernia repair in
1962 [16, 17]. Irving Lichtenstein (19202000) pioneered
the use of mesh in an open approach to affect a tension-free
repair of inguinal hernias [18]. He presented his findings in
1986 [1]. After an initial period of uproar over the
technique, this repair has become the gold standard for
open hernia repairs [19]. The tension-free concept in
inguinal hernia repair aims to (1) augment the weak back
wall (collagen defect) of the inguinal canal using prosthetic
material, thus reducing the recurrence rate, and (2) avoid
tension, unlike tissue repair, thus reducing acute and
chronic pain after the operation.
The key principles of the Lichtenstein operation were
comprehensively described by P. Amid [20, 21] and more
recently by H. Gai [22]. It is interesting that Amid
emphasizes proper fixation of the mesh as an important
technical step in the prevention of recurrences; he states
that the mesh should be securely sutured to the inguinal
ligament. Furthermore, in case of concomitant femoral
hernia, the body of the mesh below the line where it is
sutured to the inguinal ligament needs to be anchored to the
ligament of Cooper. In addition, Amid postulates that the
mesh should be fixed to the rectal sheath medial to and
above the pubic tubercle because the slightest movement of
the mesh from the pubic tubercle due to folding or
shrinkage can cause recurrence after prosthetic repair. This
extensive description of fixation techniques calls into
question the Lichtenstein concept of tension-free repair. In
contrast to the anterior mesh repair, which apparently needs
careful fixation, the posterior placement of a large piece of
mesh in the preperitoneal space covering the whole
myopectinal orifice of Fruchaud with wide overlapping of
all possible hernia gaps works according to the principle of
Pascal [23, 24]. The posterior repair then allows the
pressure of the abdomen to keep the mesh pressed against
the defect, and due to the overlap of mesh around the
defect, recurrence is prevented. According to this working
mechanism, it is understandable that the posterior repair is
perfectly tension free, even under physical stress, thus there
should be no need for fixation. Although Stoppas operation
is very good at preventing recurrence, the big midline
incision and the large amount of dissection required, the
associated pain, and the time needed to complete the repair
have kept this technique from being routinely used in the
typical hernia patient [1]. Laparoscopic hernia repair has
the advantages of Stoppas technique but avoids the
disadvantages of a big abdominal incision.
Laparoscopic/endoscopic hernia repair (transabdominal
preperitoneal patch plasty; total extraperitoneal patch
plasty)
The guidelines published by the European Hernia Society
(EHS) in 2009 [2] give the following conclusions and
recommendations: Endoscopic inguinal hernia techniques
result in a lower incidence of wound infection and
hematoma formation and an earlier return to normal
activities or work than the Lichtenstein technique (level
1A). Endoscopic mesh techniques result in a lower
incidence of chronic pain/numbness than the Lichtenstein
technique (level 1B). For recurrent hernia after conventional
open repair, endoscopic inguinal hernia techniques result in
less postoperative pain and faster convalescence than the
Lichtenstein technique (level 1B). From the perspective of the
hospital, an open mesh procedure is the most cost-effective
operation for treatment of primary unilateral hernias (level
1B). From a socioeconomic perspective, an endoscopic
procedure is probably the most cost-effective approach for
patients who are employed, especially for patients with
bilateral hernias (level 1B). In costbenefit analyses including
quality of life, endoscopic techniques may be preferable since
they cause less numbness and chronic pain (level 1B).
For the repair of recurrent hernia after conventional open
repair, endoscopic inguinal hernia techniques are recom-
mended (grade A). When only chronic pain is considered,
endoscopic surgery is superior to open mesh (grade A).
Consideration of an endoscopic technique is recommended
if a quick postoperative recovery is particularly important
(grade A). From a socioeconomic perspective, an endoscop-
ic procedure should be proposed for the working population,
especially for patients with bilateral hernias (grade A).
Currently, 42% of all inguinal hernia repairs in Germany
are performed with laparoscopic/endoscopic techniques
(TAPP 24%, TEP 18%) (Statistisches Bundesamt 2006
Wiesbaden, Fachserie 12, Reihe 6.2.1. 2006). The advan-
tages of this new patient-friendly approach are: (1) minimal
trauma to the abdominal wall, resulting in less pain, almost no
Langenbecks Arch Surg (2012) 397:271282 273
infection, and a very low rate of hematoma formation; (2) no
cutting or suturing of fascia structures (aponeurosis of external
abdominal oblique muscle; transverse fascia), which is
notorious for producing pain in Lichtenstein and Shouldice
repairs; (3) complete absence of tension due to Pascals law of
physics, resulting in less risk of chronic pain; and (4) greater
distance from the testis, resulting in less probability of direct
damage to the testes or severe disturbing vascularization.
Between the laparoscopic operating field and the testes, there
are numerous collateral vessels which will continue to provide
blood to the testes if the operation leads to a disruption of the
intra-abdominally located part of the testicular vessels.
A disadvantage of laparoscopic/endoscopic inguinal
hernia repair is that the operative procedures are difficult,
implying a high risk of complications, especially when the
surgeon has not yet overcome his so-called learning
curve. Indeed, even for a surgeon with advanced skills
and considerable surgical experience it takes time to learn
the revolutionary new technique due to the unfamiliar
anatomy, new instruments, and completely new coordination
of the eyebrainhand axis required to use the video-
endoscopic technique. Studies show that use of endoscopic
inguinal hernia techniques results in a longer operation
(level 1A). However, a large prospective study showed
that with a highly standardized surgical technique and
well-structured education, the results achieved by trainees
were not different from the results of experienced surgeons
(except for operating times) [25].
The operative technique used for laparoscopic/endoscopic
hernia repair has been described several times in detail [25
28]. In these studies it was clearly demonstrated that in
experienced hands, both TAPP and TEP are safe and
effective techniques for treatment of inguinal hernia.
Moreover, it was shown that all types of inguinal hernia
can be successfully treated with TAPP [25], even the most
complicated cases: strangulated hernias [29], scrotal hernias
[30], hernias after radical transabdominal prostatectomy [31],
and recurrences after previous preperitoneal repair [32].
Furthermore, the outcomes of patients who have undergone
TAPP for bilateral hernia are in no way worse than after
repair of a unilateral hernia [33].
Recently, the key points of the techniques have been
described and validated according to the criteria of evidence-
based medicine (Oxford Classification) by Kukleta and
Bittner (for TAPP) and by Chowbey, Kckerling, and
Lomanto (for TEP).
Technical key points of TAPP
Statements and recommendations in this section are based
on the guidelines of the International Endohernia Society
[IEHS] 2011 [34].
1. There is no definitive evidence that the open entry
technique for establishing pneumoperitoneum is superior
or inferior to the other techniques currently available
(level 1A).
When establishing pneumoperitoneum to gain access
to the abdominal cavity, extreme caution is required. Be
aware of the risk of injury.
The open access should be utilized as an alternative to
the Veress needle technique, especially in patients after
previous open abdominal surgery (grade A).
The technique used for access should be adapted in
the case of obesity, previous intraabdominal surgery, and
abdominal wall hernias (grade C).
2. The radially dilating trocars cause less acute injuries
(bleeding at trocar site) and less chronic tissue damage
(trocar hernias) (level 1B). The cutting trocars should
be avoided (grade A).
3. There are not enough data available on the influence of
the particular steps of the surgical technique and the
individual performance on the outcome (level 5). As a
result, the following statements and recommendations
are mainly based on expert opinion:
a. Removing adhesions between the omentum or the
bowel and the peritoneum of the groin or the
hernial sac is generally not necessary. It carries
additional risk of intestinal injury. Reduction of the
hernial sac, including adherent content, if existing,
should be done en bloc.
b. A wide incision in the peritoneum is recommended
to achieve broad and clear access to the preperitoneal
space. The peritoneal incision is made 34 cm above
all possible defects from the spina iliaca anterior
superior (ASIS) to the ligamentum umbilicalis
medialis (MUL), which does not have to be
transected. If more space is needed, a cranial
extension of the peritoneal incision parallel to
the MUL may be helpful.
c. It is important to follow a precise operative strategy
when doing the complete anatomical dissection of
the pelvic floor, which is necessary for flat and
wrinkle-free placement of the mesh.
d. The extent of dissection reaches medially 12 cm
beyond the symphysis pubis to the contralateral
side, cranially 34 cm above the transversalis arch
or any direct defect, laterally to the ASIS, and
caudally at least 45 cm below the ileopubic tract at
the level of the psoas muscle and 23 cm below
Coopers ligament at the level of the superior arch
of the pubic bone. It is recommended that the
abdominal wall be dissected all along the anatom-
ical landmarks (epigastric vessels, rectus muscle,
transversalis fascia, pubic bone) but not too close to
274 Langenbecks Arch Surg (2012) 397:271282
the peritoneal flap, thus avoiding peritoneal tears or
a lesion to the urinary bladder. The resulting
preperitoneal space has to accommodate a mesh
of adequate size. A small mesh may be a risk factor
for recurrence after laparoscopic inguinal hernia
repair (level 2A). Therefore, a mesh size of at
least 1015 cm is recommended (grade A).
Slitting of the mesh with creation of a new
inner inguinal ring is not advisable (grade B).
Cutting a slit in the mesh to allow the structures
of the funicle to pass through the mesh may be
a risk factor for recurrence after laparoscopic
inguinal hernia repair (statement level 3).
e. The level of the dissection plane within the
avascular spin-web space between the internal
and external layer of peritoneum is crucial. The
objective is to retract all peritoneal sack and
corresponding pre-, extra-, and retroperitoneal fat
tissue by nearly exclusively blunt dissection from
the hernia orifices down to the middle of psoas
muscle (parietalization), 45 cm below the
ileopubic tract. The preservation of the spermatic
fascia and of the lumbar fascia protects the
fragile parietal structures (vas deferens, vessels,
and nerves) that are located in the parietal
compartment of the preperitoneal space [35].
f. Whereas dissection of a direct hernia sack is a
simple procedure, dissection of an indirect sack may
be very difficult. The following steps are recom-
mended: first, complete dissection of the space of
Retzius (medial) and Bogros (lateral). Second,
remove all adhesions between the hernia sack
and other structures, including the spermatic cord
and the cremasteric tube, the epigastric vessels,
the superior crus of the transversalis arch, and
the ileopubic tract, thus isolating the hernia.
Third, look for a lipoma and remove it before
dissecting the sack (grade B). In some cases,
after the lipoma has been removed from the top
of the hernia sack can more easily be reached.
Cord lipomas or lipomas in the femoral canal
may mimic a primary hernia or hernia recurrence
or become symptomatic at a later point (level
2 C). Fourth, in case of unclear anatomy of the
hernia content, first identify the spermatic vessels
very proximally (caudally and laterally), then
dissect the hernia sack while continuously main-
taining a view of the vessels, starting from caudal
laterally and then going to cranial medially. If dense
adhesions to the cord structures are present in a long
hernia sac, an exception may be made and the sac may
be transected at the level of the inner inguinal ring in
order to prevent injury to the cord structures (grade
D). Fifth, the incidence of seromas in direct hernias
can be significantly reduced when the lax trans-
versalis fascia is inverted and fixed to Coopers
ligament (level 2B).
g. The mesh (at least 1015 cm) should not be
implanted until dissection of the entire myopec-
tinal orifice has been completed. Less than 2
3 cm of mesh overlapping the hernia openings
may lead to a protrusion of the mesh into the
defect. The larger the hernia opening, the more
overlap there should be. In large direct defects,
the danger that mesh will protrude into the
opening is increased (level 4).
In order to avoid recurrence, the minimum
distance between the margin of the prosthesis
and that of the hernia opening should be equal to
the diameter of the opening in hernias of size 2 cm
or larger. In direct hernias, medial overlapping
should be >4 cm (grade D).
h. In laparoscopic hernia repair, fixation is not
necessary to enhance the stability of the recon-
struction but is needed to prevent dislocation of the
mesh during the very early postoperative period.
Laparoscopic hernioplasty works according to the
physical law of Pascal, thus fixation does not
compensate for inadequate mesh size or overlap.
Fixation and non-fixation of the mesh are associ-
ated with equally low recurrence rates in both
TAPP and TEP; however, in most studies the
hernia opening was small (<3 cm) or not measured.
Consequently, non-fixation could be considered
in type LI, II, and MI, II hernias (EHS
classification) (grade B). For TAPP and TEP
repair of big defects (LIII, MIII), the mesh
should be fixed (grade D).
Staple fixation is associated with a higher risk
of acute and chronic pain than non-fixation. Fibrin
glue fixation is associated with less acute and
chronic pain than stapling (level 1B), thus use of
fibrin glue should be considered to minimize the
risk of postoperative acute and chronic pain
[36] (grade B). However, in patients with a very
large direct hernia defect (diameter, >4 cm) a
stapling device or a larger mesh (1217 cm) is
preferable to provide more strength, but this is
expert opinion (grade D).
i. The last step of the operation should be thorough
closure of the peritoneal incision (grade C), which is
best done using a running suture with absorbable
suture material (grade D). Incomplete peritoneal
closure or its breakdown in laparoscopic preperito-
neal hernia repair increases the risk of bowel
obstruction (statement level 3).
Langenbecks Arch Surg (2012) 397:271282 275
Technical key points of TEP
Statements and recommendations in this section are based
on the guidelines of the IEHS 2011 [34].
In TEP operations, the dissection technique used for the
groin is the same as that outlined above for TAPP. The only
difference between the techniques is the approach to the
groin. Direct open access with the Hasson trocar via a 12-
cm subumbilical incision on the side of hernia and opening
of the rectus sheath, followed by enlargement of the space
between the rectus muscle and the posterior sheath, is a
simple and reproducible technique for accessing the
preperitoneal space (level 4). Balloon dissection should be
considered for extra-peritoneal space creation, especially
during the learning period, when it is difficult to find the
correct plane in the preperitoneal space (grade A).
There are two alternatives for the trocar placement. The
first is to place two 5 mm working ports in the midline, and
midway between the camera port and the pubic symphysis.
The midline ports have the advantage of allowing access to
both sides with equal ease, and minimal risk of injuries to
the inferior epigastric vessels. Alternatively, the second
working trocar (5 or 10 mm) can be placed after lateral
dissection, approximately 34 cm superior and 12 cm
anterior to the anterosuperior iliac spine. Lateral working
trocars are favored when mesh overlap over the midline is
perceived to be difficult (grade D). When approaching the
groin, very similar to TAPP, the dissection should extend
superiorly up to the subumbilical area, inferiorly to the
space of Retzius, infero-laterally till the psoas muscle and
Bogros space until the spina iliaca anterior superior is
reached, and medially beyond the midline. The landmarks
to be visualized are the pubic bone, Coopers ligament,
inferior epigastric vessels, cord structures, the myopectineal
orifice boundaries, and the fascia over the psoas muscle.
Posteriorly, the peritoneum is reflected to the point at which
the vas deferens turns medially (level 3).
As for TAPP, complete parietalization of the vas deferens
and the testicular vessels needs to be performed. Complete
dissection of the whole pelvic floor (anatomical) should be
done for flat placement of the mesh to cover the entire
myopectineal orifice, and prevents its folding (grade B).
When approaching and dissecting the preperitoneal space,
the incidence of producing peritoneal tears is 47% (level 3).
It is recommended that peritoneal tears be closed whenever
feasible to prevent adhesions. Techniques for the closure of
a peritoneal opening include pre-tied suture, loop ligation,
endoscopic stapling, and endoscopic suturing.
Before placement of the mesh, a large direct sac should
be inverted and anchored to Coopers ligament to decrease
the risk of seroma and external hematoma formation (grade
B). Dissection of the indirect hernial sac, for the most part
blunt, is performed under exposure of the spermatic cord/
round ligament and all inguino-femoral hernial orifices.
Complete dissection of large indirect sacs may be difficult,
and carries a risk of injury to the cord structures or may
disturb blood circulation to the testis. If there are extensive
and dense adhesions between the sac and the cord
structures, a large indirect sac may be ligated proximally
and divided distally at the level of the inner inguinal ring
(grade C). Mesh placement follows the same rules as for
TAPP. Uprolling of mesh is a main cause of recurrence.
Insufficient preperitoneal dissection (parietalization) is
the main cause of uprolling of mesh (level 3). To prevent
this, extensive preperitoneal dissection is critical. Between
the lower edge of the mesh and the dissected peritoneal sac,
as with TAPP, there should be a distance of about 12 cm.
To ensure that the mesh is in the correct position,
desufflation of the retropneumoperitoneum should be
performed under vision (grade B).
Comparison of TAPP and TEP
Statements and recommendations in this section are based
on the guidelines of the IEHS 2011 [34].
Potentially serious adverse events are rare after both TAPP
and TEP (level 2A). Both techniques are acceptable treatment
options in inguinal hernia repair, but data are insufficient to
allow conclusions to be drawn about the relative effectiveness
of TAPP versus TEP (grade B) [37, 38].
There is currently only one published randomized
controlled trial comparing TAPP and TEP [39]. The authors
found less early postoperative pain (p<0.02) and a shorter
hospital stay (p=0.03) after TAPP, but the number of
patients randomized to the two techniques was very small
(n=50, level 2B). With regard to overall complication rates,
there is no obvious difference between TAPP and TEP
(level 3). Analysis of the large studies reporting results of
TAPP and TEP shows a tendency toward more vascular
complications (0.42 vs. 0.25) and conversions (0.66 vs.
0.16) after TEP repair, but more visceral lesions (0.21 vs.
0.11) and port-site hernias (0.6 vs. 0.05) after TAPP repair
(Misra, IEHS Guidelines 2011 [34]). TAPP and TEP have
noticeable learning curves. TAPP has a shorter
operation time when performed by inexperienced and
experienced surgeons (level 3), thus indicating that it
might be easier to perform, but there is no level 1
evidence to support this belief. According to expert
opinion, TEP may be advantageous in connection with
direct hernias, especially in bilateral locations, but
indirect herniasand especially large hernias (scrotal)
may be more easily operated on using TAPP (level 5).
Moreover, experts agree that TAPP is better in patients with a
strangulated hernia [29], in patients with a recurrence after
previous preperitoneal repair [32], and in hernia patients with
276 Langenbecks Arch Surg (2012) 397:271282
a history of previous radical transabdominal prostatectomy
[31] (level 5).
Comparison of TAPP/TEP and Shouldice
According to a meta-analysis of 18 randomized prospective
controlled studies [40], total morbidity is significantly less
after laparoscopic surgery (254/1,830; 13.9%) compared to
the Shouldice repair (292/1,773; 16.5%) (p>0.05). None of
the studies reports an intraabdominal bowel lesion; two
lesions of the urinary bladder occurred after laparoscopy
and one after Shouldice (non-significant (n.s.)). Frequency
of hematomas, nerve injuries, pain-associated parameters
such as time to return to work and chronic inguinal pain are
significantly less after TAPP/TEP (p<0.006 to p<0.00007
depending on the parameters assessed). There is no
difference with regard to wound infection, urinary reten-
tion, vascular lesions, testicular atrophy, or recurrence rate.
Operation time (54 vs. 68 min) and frequency of seroma
(1.2% vs. 4.4%) are lower after Shouldice operation
compared to TAPP/TEP (p<0.00002). In accordance with
this meta-analysis, a randomized clinical trial published by
Arvidsson et al. [41] reported a cumulative recurrence rate
of 6.6% 5 years after TAPP, compared to 6.7% in the
Shouldice group (n.s.). However, the recurrence rates at
different hospitals ranged from 5% to 13% in the TAPP
group and from 2% to 14% in the Shouldice group, and
rates for individual surgeons ranged from 0% to 23% and
from 0% to 19%, respectively. In addition, when calculating
a surgeons performance score the authors found a
significant correlation between a low score and a 5-year
recurrence rate (p=0.019), indicating that recurrence is at
least partly due to technical failure. Neumayer et al. [42]
came to a similar conclusion, reporting a higher recurrence
rate (>10%) among surgeons who had previously
performed fewer than 250 laparoscopic operations than
among surgeons with more experience (<5%). This
reflects the long learning curve and complexity of the
laparoscopic technique. However, discussion of the
causes of recurrence should take into account that,
besides the difficulties inherent in adapting to a
completely new and infamiliar technique, the mesh size
used in the study published by Arvidsson et al. [41] was
only 712 cm, which might be a second factor explaining
the relatively high recurrence rate after TAPP. Confirming
this conclusion, a detailed analysis of the Neumayer study
[42] showed that the mesh size was indeed significantly
smaller in patients with a recurrence than in patients
without. Consequently, given the fact that polypropylene
mesh shrinks up to 40% [43], Arvidsson et al. [41]
emphasize the need for a large mesh to achieve good
coverage of the entire inguinal area.
A recently published randomized trial with 867 patients
comparing discomfort 5 years after laparoscopic and
Shouldice inguinal hernia repair [44] demonstrated that
patients after TAPP had a significantly shorter period of
sick leave (p<0.001) and a significantly lower combined
VAS pain score (p<0.001) for the first postoperative week.
Interestingly after 2 years, there was also a statistically
significant difference between discomfort rates, favoring
laparoscopy (11.2% vs. 16.4%), but after 5 years, discom-
fort was reported by 8.5% of the TAPP group and 11.4% of
the Shouldice group (p=0.156; n.s.).
Comparison of TAPP/TEP and Lichtenstein:
complications and recurrence rates
There are nearly 100 published randomized trials, system-
atic reviews, and meta-analyses comparing laparoscopic
inguinal hernia repair and open techniques. Most reviews
include all types of open surgery and do not differentiate
between open flat mesh repair (Lichtenstein), open preper-
itoneal mesh repair, open plug, or suture repair [45, 46].
The largest meta-analysis comparing TAPP/TEP versus
only Lichtenstein was performed by Schmedt et al. [47].
These authors found a total of 34 trials comparing TAPP/
TEP with various open mesh repairs and suitable for a
formal meta-analysis, but trials that used the Lichtenstein
repair (n=23) were analyzed separately. According to this
meta-analysis, significant advantages of the endoscopic
procedures over the Lichtenstein repair include a lower
incidence of wound infection, a reduction in hematoma
formation and nerve injury, an earlier return to normal
activities or work, and a lower incidence of chronic pain
syndrome. No difference was found in total morbidity or in
the incidence of intestinal lesions, urinary bladder lesions,
major vascular lesions, urinary retention, or testicular
problems. Significant advantages of the Lichtenstein repair
included a shorter operating time, a lower incidence of
seroma formation, and fewer hernia recurrences. The
recurrence rate is dependent on technical details, and
therefore on the education and experience of the surgeon.
Similar rules apply for open and endoscopic mesh
implantation; however, the endoscopic approach seems to
be more complex. In various analyses, the following causes
of recurrence were identified: inadequate dissection of the
preperitoneal space, slit in the mesh, inadequate mesh size,
inadequate overlapping, improper fixation (in hernias with
defect diameters of more than 45 cm), folding or twisting
of the prosthesis, missed defect, and lifting of the mesh
secondary to hematoma formation [47].
Corresponding to the data of the meta-analysis published
by Schmedt [47], in a large randomized trial Neumayer et
al. [42] found that recurrence was significantly more
Langenbecks Arch Surg (2012) 397:271282 277
common after laparoscopic repair than after open repair of
primary hernias (10.1% versus 4.0%); however, for expe-
rienced (more than 250 procedures) laparoscopic surgeons,
the recurrence rate was in the same range as open surgery
(5.1% versus 4.1%). Furthermore, in a reevaluation of their
data [48], the authors found that a significantly smaller
mesh was implanted in the patients with a recurrence than
in the non-recurrence patients (8.10.6 cm vs. 8.5
1.3 cm). In their report of 5-year outcomes of laparoscopic
and Lichtenstein hernioplasties, Heikkinen et al. [49]
conclude that both techniques have a low risk of hernia
recurrence if proper mesh size is used.
Eklund et al. emphasize the level of individual technical
skills as a main factor in recurrence [50]. In their large
randomized trial comparing TEP with Lichtenstein repair,
they found a cumulative recurrence rate of 3.5% in the TEP
group and 1.2% in the Lichtenstein group. This difference
was significant, but a test for heterogeneity revealed
significant differences between individual surgeons. The
exclusion of one surgeon, who was responsible for 33% of
all recurrences in the TEP group, lowered the recurrence
rate to 2.4%, which was no longer statistically significant
different from that of the Lichtenstein group.
In a systematic review of 15 randomized trials compar-
ing TAPP with open mesh repair, McCormack et al. found
similar recurrence rates for the two techniques (2.5% vs.
2.1%) [38]. Similarly, Kuhry et al. analyzed 15 randomized
trials comparing TEP with open mesh repair and also found
no difference in recurrence rates (3.2% vs. 4.5%) [46]. In a
large, recently published randomized controlled trial com-
paring TEP with the Lichtenstein operation, no difference
was found in recurrences (3.8% vs. 3.0%; n.s.). TEP was
associated with more adverse events during surgery but less
postoperative pain, faster recovery of daily activities,
quicker return to work, and less impairment of sensibility
after 1 year [51].
Eklund et al. published the results of a randomized
multicenter study comparing TAPP with the Lichtenstein
technique for treatment of recurrent inguinal hernia [52].
The authors found significantly fewer complications at one
week after TAPP (11% vs. 33%; p<0.001), less postoper-
ative pain, and shorter sick leave (8 vs. 16 days) when
compared to the Lichtenstein repair. The randomized trial
comparing TEP with Lichtenstein published by Kouhia et
al. [53] reported the same resultearlier return to work
after TEP (14.8 vs. 17.9 days), as well as significantly less
chronic pain (8.2% vs. 27.7%). A meta-analysis of four
RCTs comparing laparoscopic with open mesh repair of
recurrent inguinal hernia confirmed these results [54].
Another meta-analysis recently published by Dedemadi et
al. [55] found significantly less hematoma/seroma for-
mation in the laparoscopic group, but duration of sick
leave was not reported.
Comparison of TAPP/TEP and Lichtenstein: pain,
quality of life, and costs
According to a large prospective study in 463 patients
undergoing Lichtenstein or TAPP elective groin hernia
repair, both patient and surgical factors influence persistent
postherniotomy pain (PPP) [56]. In this study, logistic
regression analysis identified four risk factors for PPP: (1)
substantial pain-related increased functional impairment at
6 months postoperatively, assessed by the validated activity
assessment [57], (2) increased preoperative pain response to
heat stimulation, (3) increased 30-day postoperative pain
intensity, and (4) sensory dysfunction in the groin at
6 months (nerve damage). Furthermore, when only preop-
erative factors and choice of surgical technique were
analyzed, a risk prediction model revealed that preoperative
pain (increased AAS), a low threshold for pain, and open
surgery increased the risk of chronic pain (PPP). The
incidence of substantial pain-related activity impairment
was significantly lower in TAPP vs. Lichtenstein patients
(8.1% vs. 16%), and particularly in patients with the highest
risk of chronic pain based upon preoperative pain-related
activity impairment and pain response to heat stimulation.
Moreover, in this study, which was the first to apply
detailed quantitative sensory testing, the reduced risk of PPP
was found to be correlated to a significantly lower incidence
of nerve injury (sensory disturbances) from the TAPP
technique using a lightweight mesh fixed by fibrin glue.
These results are confirmed by the recently published
data of the Swedish Multicenter Trial of Inguinal Hernia
Repair by Laparoscopy study group [58]. Interestingly,
5 years after surgery the Swedish group found nearly the
same difference in the occurrence of chronic pain between
the patients undergoing TEP and Lichtenstein (9.4% vs.
18.8%, respectively) as in the study published by Aasvang
[56] between TAPP and Lichtenstein (8.1% vs. 16.0%,
respectively). In a prospective study with matched-pair
analysis, Myers et al. [59] demonstrated that TEP repair
results in less postoperative pain, a quicker return to normal
functional status, and significantly improved quality-of-life
outcomes for both mental and physical health when
compared to Lichtenstein repair.
Eklund et al. [60] performed a long-term cost-
minimization analysis comparing TEP with Lichtenstein
repair and found in their RCT that TEP had a small but
significant increase of overall costs compared with the open
repair. By contrast, in a systematic review of 11 RCTs and
seven prospective non-randomized trials comparing costs
and quality of life after endoscopic vs. open inguinal hernia
repair, Gholghesaei et al. concluded that from a societal
perspective, endoscopic repair entails costs similar to open
surgery but offers extra benefits to the patients in terms of
quality of life and pain [61].
278 Langenbecks Arch Surg (2012) 397:271282
In a costutility analysis of treatment options for
inguinal hernia in 1,513,008 adult patients, Stylopoulos et
al. used a Markov Monte Carlo decision model and came to
similar results [62], concluding that laparoscopic hernia
repair is a cost-effective approach and is associated with
higher quality of life benefits at a lower cost. The authors
stated that given this finding, increased efforts to make
laparoscopic herniorraphy easier to perform could ultimately
reduce health care costs.
In order to approach this aim, two requirements must be
met: (1) strict standardization of the technique [34] and (2)
systematically structured education. Both are necessary to
perform a safe operation without any major complications
in a reasonably short time. Safe surgical technique, short
time in the operating theater, and the application of non-
disposable instruments are the indispensable essentials of a
cost-effective and efficient operation.
Selection of mesh material
Currently, there are more than 150 different meshes
available on the market, indicating that the search for an
ideal mesh continues [63, 64]. The problem is that there is
no mesh which is biologically inert [65], thus all meshes
trigger a foreign body reaction. The foreign body reaction is
fairly uniform, regardless of the type of foreign material,
but the extent of the reaction is affected by the amount of
material present [66]. This reaction should allow integration
of the mesh by soft tissue ingrowth but prevent
encapsulation by bridging or excessive scar tissue formation,
which may lead to a reduction in abdominal wall compliance
and cause pain, adhesion formation, or unpredicted
mesh shrinkage.
According to a large review of the literature, the most
important properties of meshes were found to be the type of
filament, tensile strength, and porosity [66]. These deter-
mine the weight of the mesh and its biocompatibility [67].
Heavy-weight meshes (>80 g/m) use thick polymers and
have small pore sizes and high tensile strength. Light-
weight meshes (<40 g/m) are composed of thinner
filaments and have larger pores (>1 mm) and a minimal
surface area. Effective porosity (pore size left after
implantation and granuloma formation around individual
mesh fibers) is the main determinant of tissue reaction.
According to experimental data, heavyweight meshes are
supposed to provoke more bridging, severe scar tissue
formation, and shrinkage, whereas lightweight meshes are
supposed to induce less or no bridging, which may
result in better tissue integration. It is unclear, however,
whether heavyweight meshes result in more clinical
complaints and chronic pain, and light meshes provide
more comfort and less pain.
One meta-analysis [68] and 17 RCTs have been
published comparing heavyweight meshes to lightweight
meshes, with nine of the studies using open surgery
[6977] and eight using laparoscopic repair [7885]. The
results were controversial and limited; only four of the
laparoscopic surgery studies [8285] had a follow-up
longer than 3 months.
Over the short term, lightweight meshes have advantages
with regard to physical fitness [80, 84, 85], daily activities
[78], and general health and bodily pain [79], and in one
study with regard to pain [81]. One study using a titanized
extra-light (16 g/m) polypropylene mesh found signifi-
cantly less seroma production when compared to a classic
heavyweight (90 g/m) mesh [84]. However, after 1 year
none of the authors reported any significant advantages of
one mesh over another with respect to chronic pain.
Accordingly, Weyhe, Schug-Pa and Klinge state in the
IEHS Guidelines [34] that in long-term comparisons, lighter
meshes with larger pores do not lead to improvements in
quality of life or a statistically significant reduction of
discomfort, but they may offer advantages in terms of
convalescence in the first few postoperative weeks (level 1A).
In the process of deciding for one mesh over another, we
should always be aware that besides the structure and the
properties of the mesh, there are at least three more factors
determining outcome after inguinal hernia repair: the
patients individual biological response to the mesh, the
surgical technique used, and the surgeons skills.
Conclusion
Worldwide, about 20 million hernia repairs are done every
year. Therefore, hernia surgery has a significant impact on
the costs of national health care systems. Of more than 70
operative techniques available today, only three are gener-
ally accepted as the best evidence-based treatment options
for inguinal hernia repair: suture repair according to
Shouldice, flat open mesh implantation according to
Lichtenstein, and the laparoscopic/endoscopic methods.
The advantages of the Shouldice operation are that it has
been used successfully over a period of several decades, it
is easy to learn, equipment is simple and cheap, it can be
performed using local anesthesia, and there is no need for
large amounts of foreign materials. Disadvantages are the
high recurrence rate and difficulty of reoperation.
The advantages of the Lichtenstein procedure are that it
is easy to learn, it can be done under local anesthesia with
simple equipment, and it has a low recurrence rate.
However, the disadvantage is the need for a mesh, which
can be costly and produces a lifelong existing foreign body
reaction, with possible involvement of inguinal nerves and
a higher probability of chronic pain.
Langenbecks Arch Surg (2012) 397:271282 279
The advantages of the laparoscopic/endoscopic techniques
are less acute and chronic pain when compared to open flat
mesh implantation, more rapid recovery, and over the long-
term, better quality of life at lower cost. There is no evidence-
based difference between the laparoscopic (TAPP) and
endoscopic (TEP) techniques. The disadvantages of the
minimally invasive techniques are the more complex
operations, more difficulty learning, longer operation
times, and higher probability of potentially life-threatening
complications.
According to the Guidelines of the EHS, TAPP and TEP
are recommended in patients with a bilateral hernia, in
patients with recurrence after previous open repair, and in
patients wanting rapid recovery.
The ideal type of mesh has not yet been identified,
although there is some evidence that a material-reduced
mesh with large pores is preferable, but selection of the
right operative technique for the specific hernia situation
and high individual surgical skills seem to be more
important and indispensable requirements for achieving
optimal hernia repair.
Conflicts of interest None.
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