Minimally Invasive Inguinal Hernia Repair

Abstract

Approximately 20 million inguinal hernia repairs are performed worldwide each year, with 800,000 commencing in the United States. About 27% of men and 3% of women undergo inguinal hernia repair in their lifetime. More than half of these are repaired using minimally invasive techniques, and about one-fifth of those are now performed robotically. Within the myopectineal orifice, inguinal hernias make up 96% of hernias undergoing operative repair, and femoral hernias comprise the remaining 4% of hernias. Femoral hernias occur more frequently in women and have a higher likelihood of incarceration at presentation. Inguinal hernias may be acquired or congenital, and the risk of a symptomatic hernia increases with intraabdominal pressure or body mass index, chronic obstructive pulmonary disease, smoking, connective tissue disease, peritoneal dialysis, an aortic aneurysm, or previous surgery (see Image. Variants of Indirect Inguinal Hernia). The diagnosis of an inguinal hernia is often made through physical examination, but can be verified with ultrasound, computed tomography, or other imaging modalities (see Images. Bilateral Direct Inguinal Hernias; Computed Tomography of an Inguinal Hernia; and Computed Tomography of a Ureteroinguinal Hernia).  Treatment options for inguinal hernias include watchful waiting, nonoperative interventions, or surgical management. Traditionally, inguinal hernias were repaired through an open approach using native tissue to close the defect. This practice was followed by the use of prosthetic mesh to achieve a tension-free repair, which later evolved into laparoscopy with a variety of mesh and fixation options.  The 2 approaches commonly used in laparoscopic inguinal hernia surgery are the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP) repair. TAPP accesses the peritoneal space within the abdomen, then creates a preperitoneal flap to access the preperitoneal space for hernia reduction and mesh placement. TEP is performed solely within the preperitoneal space.  The TEP approach limits intraabdominal injury, but TAPP allows ready assessment of the intraabdominal region. TEP is more technically demanding and is associated with a steeper learning curve, but both techniques are comparable with respect to recurrence, chronic pain, and adverse events. Several modifications, mesh fixation options, trocar placements, and strategies for managing rare and bilateral hernias are available in both approaches. Laparoscopic inguinal hernia repair is associated with quicker recovery, less postoperative and chronic pain, and fewer wound infections compared with open surgery. Laparoscopy allows a clear view of the myopectineal orifice and surrounding structures, and is used successfully even in cases of incarceration or strangulation. There is a longer learning period to master laparoscopic inguinal hernia repair and to become familiar with inguinal anatomy from a laparoscopic perspective. Approximately 32 cases are required to achieve proficiency. Open repair can be performed with general, regional, or local anesthesia, whereas laparoscopic repair is conducted under general anesthesia. The choice of surgical approach is based on factors including comorbidities, body mass index, recurrence, and bilaterality, as well as surgeon preference and proficiency. Robotic surgery offers high-definition 3-dimensional visualization and potentially improved ergonomics compared with laparoscopic or open approaches. The instrumentation polyarticulates and, together with tremor control, enables precise manipulation. Both TAPP and TEP approaches have been developed within robotic systems; TAPP is most commonly used. Since the implementation of robotic-assisted surgery, its utility has expanded in a range of surgical cases, including abdominal wall hernia repair. However, robotics can be more costly and time-consuming, and only offers a small reduction in pain and return-to-work intervals. Hernia recurrence and complication rates are not significantly different from those after laparoscopic repair, although the learning curve may be shorter with the robotic approach. Although the robotic approach has not shown major clinical benefits to date, its adoption has been widespread and is thought to have driven the large increase in the use of minimally invasive inguinal hernia repair. Study results have demonstrated an advantage of the robotic approach in complex and recurrent hernias. The use of robotics in surgery will likely continue to expand as technological sophistication advances.