Objective

In Japan, laparoscopic inguinal herniorrhaphy(LH) is not popular. We performed a retrospective study to evaluate the results of LH in our hospital.

Patients

Between August 1992 and February 2008, 286 patients with 315 hernias were operated on at our department.

Standard method of LH in our hospitalTransabdominal preperitoneal approach

Veress needle is inserted via umbilicus

Trocar size umbilicus:5mm 　 right:5mm 　left:3mm

Umbilicus ： 30°laparoscopeRight ： scissors, forceps, needle holder　　 　 introduction of mesh and tackerLeft ： forceps

Mesh ： polyester or polypropylene soft　　　（ average size:14×9cm ）

1.umbilicus2.right flank3.left flank

12 3

The advantage-11. Improved cosmesis

LH Postoperative 7 months

LH Postoperative 7 months

Open repair Postoperative 2 years

Open repair Postoperative 2 years

The advantage-22. Less postoperative pain　 Earlier return to normal activity　 Less chronic postoperative pain

《 meta-analysis of randomized control trial 》

・ less postoperative pain, more rapid return to normal activity　 The EU Hernia Trialists Collaboration: Br J Surg 87:860-867, 2000

・ less persisting pain The EU Hernia Trialists Collaboration: Ann Surg 23:322-332, 2002

・ lower incidence of chronic pain　　 Schmedt CG, et al: Surg Endosc 19:188-199, 2005

The advantage-33. Initial visualization of a recurrent hernia defect　（ the avoidance of scar tissue dissection around the area of the previous repair ）

plugplughernia defecthernia defect hernia defecthernia defect

Lt. direct hernia after Mesh-plug repairLt. direct hernia after Mesh-plug repair

The advantage-44. Initial visualization of a combined hernia defect

Rt. combined herniaRt. combined hernia

rt. indirect herniaherniart. indirect herniaherniart. direct herniahernia

The advantage-55. No additional incision to treat bilateral hernias

　《 prospective randomized controlled clinical study 》

With relation to open tension-free repair

・ higher cost

・ less postoperative pain

・ earlier return to work

Sarli L.et al.: Surg Laparosc Endosc Percutan Tech 11:262-267, 2001

The advantage-66. Evaluation of incarcerated hernia （ in TAPP ）

hernia defecthernia defect

small bowelsmall bowel

hernia defecthernia defect

uterine tubeuterine tube

ovaryovary

Rt. indirect herniaRt. indirect herniaRt. femoral herniaRt. femoral hernia

The advantage-77. Diagnosis of unsuspected contralateral hernia （ in TAPP ）

※In our practice, it is 3.8% （ 11/286 ） .

・ The reported laparoscopically detected incidence of occult contralateral hernias is between 11.2% and 50%. Koehler RH.: Surg Endosc 16:512-520, 2002

The disadvantage-11. Increased operative cost （ general anesthesia, equipment ）

But

・ The total cost for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense. 　 Heikkinen T. et al: Surg Endosc 12:1199-1203, 1998

・ From a societal perspective, laparoscopic approach can be a cost-effective treatment option for inguinal hernia repair.　 Stylopoulos N. et al: Surg Endosc 17:180-189, 2003

The disadvantage-2

2. Specific training and long learning curve

Learning curve is

・ 30–50 cases　 DeTurris SV. et al: J Am Coll Surg 194:65-73,

2002

・ 40 procedures　 Lim M. et al: Surg Endosc 20:1453-1459, 2006

※ Some authors have quantified the LH learning curve at 30–250 hernia repairs.

The disadvantage-3

3. Major complications and recurrences during the learning curve

※We experienced two severe complications. （ one bladder injury and one trocar site hernia ）

　〔 Reported serious complications 〕　　　 ・ visceral injury　(bladder, intestine, etc. ） ・ vascular injury （ iliac artery, etc. ） ・ trocar site hernia　　　　 ・ bowel obstruction　 ・ testicular ischemia　・ nerve injury （ genitofemoral nerve, etc. ）

Conclusions

1. Laparoscopic herniorrhaphy has many advantages for both experienced surgeons and patients.

2. The widespread adoption of laparoscopic herniorrhaphy needs cost saving and surgeon’s technical skill.