activities.

90 In a study of 168 patients randomized to either

TEP or Lichtenstein repair, the 5-year recurrence rates were
extremely low in both groups.91,92 Similarly, a study of 200 male
patients randomized to either ambulatory TEP or Lichtenstein
repair demonstrated no recurrences in either group after 1 year.93
Because laparoscopic surgery requires specialized instruments
and longer operative times, its cost is higher than conventional
open repair; however, the potential financial benefit
of shorter recovery and decreased pain may offset these costs
in the long term.
Perhaps the most salient difference between open and
laparoscopic techniques is the number of cases needed to
develop technical proficiency. In a randomized controlled trial
performed by the Veterans Affairs Cooperative Study, 2-year
recurrence rates were 10.1% in patients undergoing laparoscopic
repair and 4.9% in those undergoing open repair, and the outcomes
of laparoscopic repairs improved after each surgeon performed
at least 250 cases.94 More recently, Lal and colleagues
found that surgeons sustained a decrease from 9% to 2.9% in
postoperative recurrences after performing 100 TEP operations.
95 Other studies also suggest surgeons develop proficiency
in these laparoscopic techniques after performing 30 to 100
cases; however, this estimate has decreased precipitously since
laparoscopic technique was first introduced.94,96,97
Although controversy persists regarding the utility
of TEP vs. TAPP, reviews to date find no significant differences
in operative duration, length of stay, time to recovery,
or short-term recurrence rate between the two approaches. In
TAPP repair, the risk of intra-abdominal injury is higher than
in TEP repair. This finding prompted the IEHS to recommend
that TAPP should only be attempted by surgeons with sufficient
experience.40 A Cochrane systematic review found that rates of
port-site hernias and visceral injuries were higher for the TAPP
technique, whereas TEP may be associated with a higher rate of
conversion to an alternative approach; however, neither finding
was sufficiently compelling to recommend one technique over
the other.97
The frequency with which the above inguinal hernia repair
techniques are performed reinforces the importance of broad
experience. The authors recommend that surgeons become proficient
in several techniques to address different manifestations
of inguinal hernias. Surgeons should tailor this experience to
optimize outcomes for each patient.