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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 4  |  Page : 133-155

History of inguinal hernia repair, laparoendoscopic techniques, implementation in surgical praxis, and future perspectives: Considerations of two pioneers

1 Retired Em. Director, Surgical Clinic, Marienhospital, Stuttgart, Germany
2 Senior Surgeon Emeritus, Pismo Beach, California, USA

Date of Submission01-Dec-2021
Date of Decision08-Dec-2021
Date of Acceptance13-Dec-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Prof. Dr. Reinhard R Bittner
Supperstr. 19,70565 Stuttgart
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_85_21

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Those who do not know the past cannot understand the present and cannot shape the future. (Helmut Kohl, Chancellor of Germany 1982–1998). INTRODUCTION: Historical development of open and laparoendoscopic inguinal hernia repair is presented. Advantages and disadvantages of currently used techniques as well as problems related to the implementation of the minimal invasive techniques in daily surgical work are discussed. MATERIALS AND METHODS: Intensive study of the literature and our own personal experience with the performance of transabdominal preperitoneal patch plasty (TAPP) and totally extraperitoneal patch plasty (TEP) were used. Systematic descriptions of the TAPP and TEP techniques to achieve the best results are summarized. The penetration rate of the laparoendoscopic techniques worldwide is reviewed. RESULTS: Laparoendoscopic inguinal hernia repair is superior to open surgery with respect to all pain-associated parameters. Profound knowledge of the anatomy of the groin, of the pathophysiology of hernia development as well as of the working mechanisms of the surgical techniques are described as being the key features for successful treatment. The worldwide penetration rate of TAPP/TEP is dependent on the respective country and varies between 1% and 80%. The main reasons for these striking differences are the preference of individual surgeons, available resources of the specific national health care systems, differences in training facilities, and even differences in insurance coverage. New imaging systems as well as robot-assisted techniques are still need to be evaluated sufficiently for final recommendations. CONCLUSION: TAPP and TEP are well-established techniques of minimally invasive repair of inguinal hernias. Both techniques are safe, reliable, and cost-effective. Despite some meaningful advantages in comparison to open surgery, the penetration rate in most of the countries, however, remains low. Improvement of training techniques and facilities is urgently needed. Robot-assisted techniques and the use of simulators may be the promoter of laparoscopic inguinal hernia repair in the future.

Keywords: History, implementation of laparoscopic techniques, inguinal hernia repair, laparoendoscopic techniques, TAPP, TEP

How to cite this article:
Bittner RR, Felix EL. History of inguinal hernia repair, laparoendoscopic techniques, implementation in surgical praxis, and future perspectives: Considerations of two pioneers. Int J Abdom Wall Hernia Surg 2021;4:133-55

How to cite this URL:
Bittner RR, Felix EL. History of inguinal hernia repair, laparoendoscopic techniques, implementation in surgical praxis, and future perspectives: Considerations of two pioneers. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jan 20];4:133-55. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/133/334566

  Introduction Top

Hernia disease is as old as the mankind. The oldest reports date back to the time of Hammurabi of Babylon (1700 BC) and the Papyrus Elbers written in ancient Egypt in 1555 BC The first surgery seems to have been done in India during the Brahmanic period 800–500 BC. Currently, hernia repair is the most frequent procedure performed by general surgeons. It is estimated that about 20 million operations per year are performed worldwide. Four very different periods characterize the development of hernia surgery. Period 1: Ancient time and Middle Ages: Knowledge of the anatomy of the groin and the pathogenesis of hernia disease was limited. Repair was mostly done by “barber surgeons.” The result was that the patients at best lost a lot of blood and their testis, but at the worst suffered from infection and passed away. Period 2: At the end of the nineteenth-century knowledge about pathogenesis and surgery of inguinal hernia disease dramatically changed. It was Eduardo Bassini (1844–1924) who recognized that a hernia is not only a simple hole in the pelvic floor but also a sequela of a weak back wall of the inguinal canal due to both a weak transversalis fascia and a weak conjoint tendon. In 1887, Bassini published a suture technique for reinforcement of the insufficiently strong back wall of the inguinal canal. His technique was rapidly adapted by the surgical community and persisted as a standard technique for more than 50 years.[1] In 1944, Edward Earl Shouldice[2],[3] described a modernized version of the Bassini repair by doubling the fascia transversalis, which up to now is recommended as the best suture technique to use in inguinal hernia repair.[4] Two problems became apparent with the Shouldice repair, however. First, the correct technique was difficult to learn and second when widely applied it resulted in a high recurrence rate,[5] more than 10%, especially in patients presenting with a large hernia opening (Type III, EHS classification[54]). Moreover, recently elaborated evidence shows that hernia disease may be caused by some disturbance of collagen metabolism;[6],[7] thus, the best suture technique will not be able to prevent recurrence in the long follow-up. Interestingly, already in 1878 Theodor Billroth postulated: “If it would be possible to produce artificial tissue showing the properties of human fascia or tendon, we would have detected the secret of radical hernia repair”. It took 80 years, for such a biocompatible artificial tissue (mesh) to be developed by Francis C. Usher[8] and was the advent of Period 3 in inguinal hernia surgery. An additional 30 years was needed to develop a reliable hernia repair technique based on the implantation of a mesh. Irving L. Lichtenstein[9] developed and published in 1989 his operation called “The tension-free hernioplasty” and he concluded that “With the use of modern mesh prosthetics, it is now possible to repair all hernias without distortion of the normal anatomy and with no suture line tension. The technique is simple, rapid, less painful, and effective, allowing prompt resumption of unrestricted physical activity”. Today, however, we know that his conclusion was rather euphemistic than based on reliable scientific studies. Indeed, using mesh repair it is possible to reduce the recurrence rate to less than 2.7%–5%.[10],[11] However, in several studies a high percentage of surgical site occurrences (SSOs) was reported, mainly chronic pain between 12% and 54%.[12],[13],[14],[15] The high percentage of chronic pain after open mesh repair may be related to excessive foreign body reaction due to less biocompatible mesh structures, to direct damage of the inguinal nerves intraoperatively or involvement of the nerves within the chronic inflammatory process of mesh integration or may be caused by incorrect fixation techniques. Realistic assessment of the working mechanism of the Lichtenstein repair will reveal that the term “tension-free hernioplasty” is rather a myth than based on data. Of course, it is true when the patient is lying on the operation table there is no tension on the tissue, but the moment the patient stands up there will be a lot of pressure through the hernia defect onto the mesh, like a lid on a pot. In summary, although the Lichtenstein repair hernia recurrence rate is low, chronic pain remains a serious problem. Despite all the improvements in operative techniques as well as in mesh technology achieved during the last decades, the incidence of chronic pain remains as high as 20%.[4],[10],[16] With the advent of minimally invasive surgery (MIS), surgeons hoped using these new revolutionary techniques would overcome the high rate of chronic pain but continue the low incidence of recurrence. It was the dawn of Period 4 in inguinal hernia surgery. According to Stoppa et al.,[17] the preperitoneal position of the mesh [Figure 1] is based on the physical law of Pascal.[18] It is the working mechanism of both minimally invasive techniques (III): the transabdominal preperitoneal patch plasty (TAPP) and the totally extraperitoneal patch plasty (TEP). As stated by Nyhus,[19]
Figure 1: Schematic demonstration of the working mechanisms the currently most popular techniques in inguinal hernia repair: I––Shouldice, II––Lichtenstein, and III––Laparoendoscopic (TAPP/TEP)

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“Stoppa reminded us of the Pascal hydrostatic principle and proved that a large prosthetic mesh placed in the preperitoneal space would remain fixed by intraabdominal pressure, the hernial orifice would be covered permanently and the mesh would be maintained in place without the need for suturing or tacking to the abdominal wall.”

In contrast to the Stoppa procedure which needs a large midline incision and is burdened immanently by acute postoperative pain and several unpleasant side-effects like hematoma or even infection, minimally invasive repair requires three small incisions only and therefore carries a very low risk for such SSOs.

In summary, the advantages of minimally invasive repair of inguinal hernia are as follows: (1) minimal trauma to the abdominal wall due to minimized access (TAPP and TEP). (2) To implant the mesh healthy tissue like the external aponeurosis is not cut like it is in the Lichtenstein operation. (3) The right plane for the mesh is between the deep layer of the transversalis fascia and the peritoneum; therefore, any contact between the mesh and the inguinal nerves that are located behind the fascia can be avoided. (4) Costly fixation devices that in addition carry the risk for causing chronic pain are not required. (5) Because the mesh is between the intraabdominal pressure and the weak groin wall, tension on the abdominal wall is not created if a sufficiently large mesh is implanted. In conclusion, due to these characteristics of the MIS repairs, postoperative pain should be less after laparoendoscopic inguinal hernia repairs in comparison to suture or open mesh repairs.

  Historical Development of Minimally Invasive Inguinal Hernia Repair Top

In the beginning of MIS of inguinal hernias, surgeons had to overcome the same problems that surgeons did in developing open hernia repairs. Surgeons were unfamiliar with the anatomy of the backside of the abdominal wall in the groin. It just seems that only little was learned from the past. W.J. Lytle[20] stated: “The operating surgeon knows little of the posterior wall of the inguinal canal, so well is it hidden from his view.” Still in the beginning of the twenty-first century, Wright et al.[21] complained:

“this may be the most serious problem associated with laparoscopic hernia repair, the learning curve is long. The principal reasons for the long learning curve are the surgeon’s lack of familiarity with the preperitoneal anatomy and the time it takes to develop the skills to operate in a confined space.”

Most strikingly, a full exploration of the neuroanatomy in the preperitoneal space was not achieved until the mid of the 90s of the last century and the beginning of this century.[22],[23],[24] Therefore, it is not astonishing that during the first decades of MIS intraoperative complications and postoperative chronic pain were due to ignorance of the anatomical structures of the groin. The result was discrediting of the new technique and the hope of achieving a better outcome than open surgery. The second mistake was that like the surgeons of old, the pioneers of MIS inguinal hernia repair believed that closure of the hole in the groin was necessary. Therefore, they used a plug to close hole which resulted in new complications.

In 1982, Ralph Ger [Figure 2] published the first case of a laparoscopic repair of an inguinal hernia. After experience in 12 patients with open abdominal surgery and concomitant inguinal hernia that Ger had managed the hernia by closing the peritoneal opening of the sac by interrupted metal clips, he developed a method for closure of the neck of the sac via laparoscopy. Ger used this new laparoscopic repair technique in one patient. He was successful and published it as a case report in 1982.[25]
Figure 2: Ralph Ger

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Ralph Ger’s pioneering work was not really noticed for nearly one decade. It was not until 1989 with the advent of MIS and the presentation of a video S. Bogojavlensky at the occasion of the 18th Annual Meeting of the American Association of Laparoscopic Gynecologists in Washington, DC, that a few surgeons showed some interest in this completely new and revolutionary repair of inguinal hernias. In comparison to laparoscopic cholecystectomy, however, development and worldwide spread of laparoscopic hernia repair proceeded extremely slowly not at just due to the unfamiliar anatomy of the back wall of the groin as mentioned above, but more importantly, hernia repair is not a simple ablative procedure but rather an operative technique to reconstruct the pelvic floor by using the implantation of a mesh.

The next steps in laparoscopic inguinal hernia repair are published in 1990 by Popp and Schultz. Popp closed the hernia defect with catgut-sutures in one female patient, but additionally enforced the region of the inguinal canal by implantation of a 4 cm × 5 cm dura-patch like in the intraperitoneal onlay mesh (IPOM) technique, which is currently used in repair of incisional hernias.[26] Schultz [Figure 3] was the first who opened the peritoneum and implanted a marlex plug to obliterate the space (hernia defect) and then he reapproximated the edges of the peritoneum in a small series of 20 patients, but Schultz did not reduce the hernia sac.[27]
Figure 3: L. Schultz

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In 1991, J.D. Corbitt [Figure 4] modified the Schultz technique. In 20 patients he opened the peritoneum using laser technology and resected the hernia sac with an Endo-GIA, then he put a Mersilene plug into the inguinal canal, but additionally he implanted a 5 cm × 5 cm patch over the inner inguinal ring.[28]
Figure 4: J.D. Corbitt

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In the same year, 1991, F. Götz [Figure 5] published the first laparoscopic hernia repair in Germany. Götz closed the hernia sac at its basis with suture and fibrin injection.[29]
Figure 5: F. Götz

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Again in 1991 Toy and Smoot ([Figure 6] F.K. Toy) performed in 11 patients a high ligation of the hernia sac and implanted a 5 cm × 7 cm PTFE-patch intraperitoneally (IPOM) without any dissection of the preperitoneal space, but they were the first who emphasized that “it was important to keep the patch larger than the defect so that increases in the intraabdominal pressure acted to secure the patch.”[30] The patch was fixed using an Endo-Hernia Stapler.
Figure 6: F.K. Toy

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Robert Fitzgibbons [Figure 7] advocated a pure IPOM technique because of its simplicity.[31] Without any opening of the peritoneum or touching the hernia sac he placed a prolene mesh, average size 9.2 cm × 6 cm, over the visible hernia opening and fixed it with several clips, but he also emphasized that a larger mesh should be used.
Figure 7: R. Fitzgibbons (2008, Stuttgart)

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Epoch-making was the lecture of Maurice Arregui “Laparoscopic pre-peritoneal herniorraphy” about his experience in 52 patients [Figure 8] given at the SAGES meeting, April 1991 in Monterey, California, and on May 22, in Indianapolis at the “Advanced laparoscopic surgery meeting: International Experience,” which were published 1 year later in 1992.[32] In several national and international meetings, “2nd G. I. Tract Laparoscopic Surgery International Meeting. Liege, Belgium, October 8–9, 1992”[37] and “American College of Surgeons 1992 Clinical Congress, New Orleans, Louisiana, October 11–16,”[38] the new technique was passionately discussed (personal communication E.L. Felix [Figure 10]). Arregui criticized the IPOM technique:
Figure 8: M. Arregui

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Figure 10: E.L. Felix

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“One must question the reliability of sewing mesh to peritoneum which has the tendency to stretch and has little strength. Moreover, placement of mesh in the peritoneal cavity invites adhesion formation. In my experience the mesh in IPOM technique is like a boat on a rough sea without any fixing point.”

Arregui deserves credit for defining two key points of modern laparoscopic hernia repair (TAPP): (1) complete dissection of the whole pelvic floor, thus not missing atypical especially medially located hernia openings and (2) preperitoneal implantation of a large flat mesh, thus avoiding migration of small meshes and keeping down the foreign body reaction, which may be induced rather by more dense plugs.

Maurice Arregui combined the experiences of the French school of surgery (Stoppa) with the new minimal invasive (access) techniques and is rightly named as the father of laparoscopic hernia repair (TAPP), which also may be called “laparoscopic Stoppa.”

Despite promising results of the new technique, the surgical community expressed severe concerns, above all about that hernia repair may change from a relatively harmless intervention outside of the abdominal cavity to a transabdominal operation burdened by the risk of potentially life-threatening damage to intraabdominal organs. To avoid these risks, a pure extraperitoneal approach to the inguinal region was developed first in France by Dulucq [Figure 11] and published in 1991,[33] 1 year later in the US by Ferzli [Figure 9] in 25 patients,[34] and in 1993 again in the US by McKernan in 34 patients.[35]
Figure 11: J-L. Dulucq, EAES 1998, Cologne

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Figure 9: G. Ferzli

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Although the principles of laparoendoscopic inguinal hernia repair being reliable for the surgical community, which were described for the first time by J.-L. Dulucq (TEP) and M. Arregui (TAPP), are still valid, the practical performance has been fundamentally improved during the following decades.

Both techniques are valuable alternatives to open inguinal hernia repair, but evidence shows advantages with respect to all postoperative pain-associated parameters. Therefore, current guidelines[4],[36] recommend:

For male patients with primary unilateral inguinal hernia, a laparo-endoscopic technique is suggested because of a lower postoperative pain incidence and a reduction in chronic pain incidence, provided that a surgeon with specific and sufficient resources is available. However, there are patient and hernia characteristics that warrant a Lichtenstein as first choice.

In summary, today laparoendoscopic inguinal hernia repair is safe, effective, and cost-efficient. Milestones for improvement of the results are as follows:

  1. Better knowledge of anatomy (especially neuroanatomy) of the groin and of the pathophysiology of hernia disease.

  2. Finding the right plan for mesh implantation and improvement of dissection techniques accordingly.

  3. Minimizing the size of the surgical instruments.

  4. Increase of mesh size and avoidance of a slitted mesh for creation of a new inner inguinal ring. Although in the first publications[34],[35] a slitted mesh with creation of a new inner inguinal hernia ring was recommended, E. Felix recognized the slit as a weak point in the mesh and advocated a double buttress technique, which means to cover the slit with a second flat mesh[37],[38] to enforce the pelvic floor without any gap. Today we know that when performing a radical parietalization (see below) and when using a large mesh, the implantation of a slitted mesh that is secured by a second mesh is no longer needed.

  5. Development of intraabdominal suture techniques.

  6. Improvement of mesh technologies.

Regarding the question “Which technique is better?” the transabdominal approach (TAPP) or the totally extraperitoneal (TEP) HerniaSurge guidelines recommend: “In laparo-endoscopic inguinal hernia repair, as TAPP and TEP have comparable outcomes it is recommended that the choice of the technique should be based on the surgeon’s skills, education and experience.”[4]

  Current Techniques in Minimal Invasive Inguinal Hernia Repair Top

Laparoendoscopic inguinal hernia repair is considered a safe, effective, and efficient technique. Furthermore, in comparison to open mesh-based repair the laparoendoscopic technique should be superior with respect to all postoperative pain. These advantages, however, are only realized if the operation can safely be performed without any severe unpleasant side-effects. Therefore, the optimal surgical technique is the key for success.

  Transabdominal Preperitoneal Patch Plasty Top

In 1994, E. Felix [Figure 10] Department of Surgery, University of California-Fresno and Center for Hernia Repair, Fresno, CA 93710, USA. [email protected] was one of the first who showed that the laparoscopic technique is also applicable in patients suffering from recurrent hernia.[39] About 8 years later we confirmed his results in a large patient population and showed that nearly all types of inguinal hernias can be successfully treated by TAPP.[40] Since that time several technical innovations were introduced to make the performance of TAPP easier and safer. Details of this continuous improvement of our technique were recently described.[41],[42]

  Technique Transabdominal Preperitoneal Patch Plasty Top

The patient is positioned flat on the operating table. Both arms are fixed to the body. The table is in head-down position by approximately 15° to 20°, and turned to the surgeon by approximately 15°. The surgeon stands on the side opposite of the hernia, and the camera guide is sitting on the contralateral side; thus, he can lean his elbow on the thorax of the patient. In this way, he is able to guide the camera much steadier without any stress.

The operation is performed in general anesthesia; thrombotic embolism prophylaxis is routinely given. Antibiotic prophylaxis is only given in patients having an increased risk for infection.[43] A urinary catheter is not routinely applied.

Step 1: Establishment of pneumoperitoneum: Which trocars are best suitable?

The establishment of the pneumoperitoneum and the introduction of the first trocar are the most important steps of the operation, because both parts of the procedure are performed blindly without a direct view. There is an extensive discussion in the world literature about which technique may be better, the closed entry using the Veress needle or the open access according to Hasson. Following the guidelines (IEHS), none of these techniques is superior to or inferior to the other entry techniques.

I prefer in all cases without previous periumbilical surgery the closed entry technique using the Veress needle. The advantage of this access is that only a very small incision (5 mm) to the ground of the umbilicus is needed to introduce a 5 mm 30° optic (our standard), whereas when applying the Hasson technique with finger exploration of the abdominal cavity to exclude adhesions, an incision of at least 15–20 mm is necessary which results in more pain, more wound complications, and more trocar hernias. I recommend always performing the safety tests according to Kurt Semm, a gynecologist from Kiel/Germany, who was the first who performed an appendectomy laparoscopically[44]––double click (snap) test, hanging drop (slurp) test, and the aspiration test. Evidence for doing these tests in favor of more safety is low; however, these tests should remind the surgeon of being very cautious, as the entry into the abdominal cavity is one of the most important steps of the operation. Furthermore, keep in mind, that more reliable information about the correct needle position is possible by observation of the initial intraabdominal pressure as well as the flow of the gas. The flow must be high and the pressure low.[45] If there are some uncertainties, I recommend an open-entry technique.[46] Alternative to the umbilicus as an entry point for the Veress needle Palmer’s point below the left costal margin can be used.[47]

The use of three-edged cutting trocars is not recommended,[43] because in comparison to the blunt tip expanding working trocars they may cause more bleeding complications, more pain and more trocar hernias. The size of the trocars should be as small as possible. The limiting factor is given by the thickness and size of the mesh as well as by the possibility for introducing a gauze swap for bleeding control or the needle holder and the needle. Our standard [Figure 12] is as follows: 5 mm for the camera at the umbilicus, 5 mm working trocar left side perforating the rectus muscle at the level of the umbilicus, and 7 mm trocar on the right side, perforating the rectus muscle too at the level of the umbilicus, for implantation of the mesh or needle holder or some gauze [Figure 12].
Figure 12: Position and size of the trocars

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Step 2: Introduction of the working trocars, first view to the abdominal cavity, and the groin: Is adhesiolysis always necessary?

Both of the working trocars must be introduced under direct view! The first view should be around the abdominal cavity to exclude other abdominal pathologies. If there are adhesions between the intraabdominal organs and the abdominal wall, it is not recommended to do an adhesiolysis except if the adhesions do not allow a sufficient view and access to the groin. If there are extensive adhesions preventing access to the lower abdomen it may be better to convert to a totally extraperitoneal approach or to open surgery depending on personal experience. It is not recommended to take down adhesions between omentum and parts of the bowel with the hernia sac composing the hernia content. This is unnecessary and burdens the risk of bowel lesion or bleeding. In these cases, the hernia sac including the contents is reduced “en bloc.”

Advantageous in comparison to the TEP technique the first laparoscopic view to the groin allows immediately a precise diagnosis of the location of the hernia, the size of the hernia defect as well as the size of the hernia sac inclusive its content, not only on the side clinically the hernia was found but also on the contralateral side [Figure 13]. According to a recently published study in patients presenting clinically with a unilateral hernia, the occurrence of an occult hernia on the contralateral side may be up to 55%.[48]
Figure 13: First laparoscopic view to the left groin in a patient with recurrent inguinal hernia

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Before opening the preperitoneal space I recommend to discuss with your camera guide the anatomical structures of the groin seen with the first view [Figure 13] and [Figure 14]. The identification of the iliopubic tract, which is a virtual line between the anterior superior iliac spine (ASIS) and the symphysis, corresponding to the inguinal ligament from outside view, is of paramount importance. Keep in mind: All important structures––great vessels and inguinal nerves––are located inferior to this tract. Therefore, all of the surgical maneuvers below the iliopubic tract should be done extremely carefully. Superior to the tract there is only one structure––the epigastric vessel––which needs special care.[49]
Figure 14: Right-sided groin. Incision line for TAPP (black line)

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Step 3: Opening of the peritoneum and entering of the preperitoneal space

I recommend a wide incision of the peritoneum, starting in front of the ASIS and generously follow the black line [Figure 14] up to the plica umbilicalis medialis. If more space is needed, for example, in patients with a narrow pelvis, the plica umbilicalis must not be cut (umbilical vessels, danger of bleeding), but in this case the incision should parallel the plica upwards. The distance between the dissection line and the iliopubic tract at the level of the epigastric vessels should be 5–7 cm. I recommend the entry to the preperitoneal space from lateral because finding the right plane to create the bed for the mesh is easier in comparison to more medially located entries. This is due to the variable course of the deep layer of the transversalis fascia which is closer to the superficial layer in this region and therefore better to identify and to protect, whereas more medially this deep layer of the transversalis fascia (“extraperitoneal fascia”) continues into the spermatic and urogenital fascia system. Keep in mind: The deep knowledge of the layers of the abdominal wall is of paramount importance [Figure 15].
Figure 15: Graphic account of the abdominal wall showing where the mesh should be placed

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Step 4: Dissection of the whole pelvic floor

The ideal dissection plane is just in front of the deep layer of the transversalis fascia, which is rapidly reached from lateral and can be followed by mostly blunt dissection up to the epigastric vessels indicating the middle of the groin separating the groin into a lateral and a medial compartment. When crossing this “midline” special care is needed not to injure the vessels and staying close to the back wall of the rectus muscle, which in this region is not wrapped by the back wall of rectus sheath. By mostly blunt dissection the space of Retzius will be opened and the urinary bladder gently pushed away from the wall [Figure 16] without any danger for an injury of the bladder when following the right plane. For detection of atypical far medially located hernia defects (supravesical hernias, recurrence after Lichtenstein), it is important to proceed with the dissection as far as about 1–2 cm beyond the symphysis to the contralateral side. The dissection down to the pubic bone and Cooper’s ligament (CL) is safe when staying close to the rectus muscle; however, when approaching the pubic bone it is important not to destroy a very thin fibrous tissue layer (extraperitoneal fascia), which protects all the tiny vessels surrounding the bone, thus avoiding unpleasant bleeding. The dissection should continue about 1–2 cm down to the pubic bone.
Figure 16: Opening of the space of Retzius

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Although the dissection of the medial part of the space of Retzius located round the symphysis easily can be done, extreme caution is advised when approaching the iliac/femoral vessels [Figure 17]. In about 20% of the patients, there is a very strong pubic branch (“corona mortis”) between the epigastric and the obturator vessels. Furthermore, in this groove between the pubic bone and the iliac/femoral vessels, and close to the lower rim of the bone, the obturator nerve and vessels are located traveling to the obturator foramen [Figure 17]; red circle].
Figure 17: Corona mortis

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Step 5: Dissection of a direct hernia, the inner inguinal ring, and an indirect hernia sac

I recommend not dissecting the hernia sac before finishing the complete anatomical dissection of the lateral compartment (Bogros) and the medial compartment (Retzius). This is especially important in obese patients and patients with large hernia sacs or difficult anatomy, for example, in recurrent hernias. When dissecting a direct hernia pseudo-sac, it is important to stay close to the wall of the pseudo-sac (enlarged fascia transversalis) detaching all the fatty hernia content; I recommend abundant application of electrocoagulation to close all the tiny vascular and lymphatic vessels of the wall for prevention of formation of large sero-hematoma postoperatively [[Figure 18]. Furthermore, recently in large direct hernia pseudo-sacs in order to decrease seroma formation in the “dead space” produced by the reduction of the hernia content several new techniques are advocated:
Figure 18: Direct hernia sac

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  1. Inversion and fixation of the weakened transverse fascia to CL or to the rectus muscle.

  2. Suture closure of the direct defect.

  3. Inversion and closure of the sac using an endoloop.[50],[51],[52],[53]

All of these three maneuvers can be done without increasing postoperative pain.

The dissection of an indirect hernia sac is more difficult because of the close attachments of the sac to the cord structures and the risk for an injury of the testicular vessels and the vas deferens. The following five rules are important to keep in mind:

  1. Before starting the reduction of the hernia sac I recommend to take down all the adhesions between the fascia spermatica and the inguinal ring, respectively, the deep layer of the transversalis fascia [Figure 19].

  2. Next step should be the opening of the anterior part of the fascia spermatica, which is wrapping the cord structures inclusive the hernia sac by cutting all the connecting fibrous tissue between the deep layer of the transversalis fascia and the spermatic fascia [Figure 20].

  3. In about 20% of the patients a lipoma accompanying the hernia sac or is located at the top of the sac may be present. It is necessary to reduce the lipoma out of the inguinal canal because if left in situ it may mimic a recurrence or cause pain in the postoperative course. My advice is at first to proceed with the dissection of the lipoma than the hernia sac will easily follow in most of the cases. In my practice, I try to preserve the vascular root of the lipoma which accompanies the testicular vessels. Therefore, it is not necessary to remove the lipoma out of the abdominal cavity and after mesh implantation the lipoma is put on top of the mesh which helps to keep the mesh in position [Figure 21].

  4. In many cases the cord structures and the hernia sac are difficult to separate because of abundantly scarred and fatty tissue. In such confusing situations in order to avoid a lesion to the cord I recommend at first to identify the testicular vessels very lateral-caudally [Figure 22] before they accompany the hernia sac and then the vessels are used as guides for the dissection up to the top of the hernia sac.

  5. In many countries like in Africa, Asia, and to some degree also in South-America children with a congenital hernia are not operated on in time, but develop step by step huge inguinoscrotal hernias during the later years and come to operation not before being in the second or third or fourth decade of life when they experience pain or incarceration. In these cases, which are rare in Germany but I have seen many times in my surgical activities in China, India, and Africa, it may be extremely difficult or even impossible to reduce the large indirect hernia sac completely. In order to perform a safe and time-effective operation, I recommend cutting the hernia sac at the level of the internal ring after careful identification and isolation of the cord structures. It is a pity that up to now there are no reliable studies with respect to possible long-term complications like formation of a hydrocele when the distal sac is left in situ.
Figure 19: Detachment of the adhesions round the inner inguinal ring

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Figure 20: Fascia spermatica is opened

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Figure 21: Big lipoma at the entrance to the inguinal canal

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Figure 22: Showing the testicular vessels as guides for safe dissection of the hernia sac

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Step 6: Parietalization of the cord structures

One of the most important operative steps to avoid a recurrent hernia is the abundant and carefully done parietalization of the cord. Parietalization means taking down all of the adhesions between the peritoneal sac (inclusive hernia sac) and the cord structures, respectively, the deep layer of the transversalis fascia in the region of Bogros and space of Retzius about 5–6 cm inferior to the ilio-pubic tract [Figure 23]A and B. After implantation of the mesh, the distance between the lower edge of the mesh and the peritoneal sac should be at least 1–2 cm. Tip: When closing the peritoneal flap the mesh must stay in place without any move. Then you can be sure that the parietalization was adequately done.
Figure 23: (A) Showing that there are still a lot of adhesions between the cord and the peritoneal sac. (B) The parietalization is completed. The mesh is attached flat to the abdominal wall. The lipoma with preserved vascular root is positioned on top of the mesh

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Step 7: Implantation of the mesh (size at least 15 cm × 10 cm)

After finishing the dissection of the whole pelvic floor (medially 1–2 cm beyond the symphysis to the contralateral side and laterally up to the ASIS (the distance is just 15 cm in cadaver model), cranially up to 5–7 cm superior the ileopubic tract and caudally 5–7 cm inferior to the tract) the implantation of the mesh (15 cm × 10 cm) is quite easy. However, it should be noted that it is indispensable to measure the size of the hernia defect. In case the size of the defect is larger than 3–4 cm (EHS classification III[54)],[ it is recommended to choose a larger mesh],[ for example],[ 12 cm × 17 cm. The mesh should consist of large pores and should have an optimal grip on the abdominal wall. Special fixation devices are not necessary.

Step 8: Closure of the peritoneal flap

It is recommended to close the peritoneum by running suture using absorbable material],[ which is safe],[ cost-effective],[ and causes less pain. Keep in mind],[ suturing demands surgical skills],[ and for trainees it may be time-consuming and stressful; however],[ there are a lot of models [Figure 24] allowing extensive training activities.[55] Attention: It is important to close the peritoneum very tight without any gaps, because even through very small gaps (about 1 cm) some small bowel can slip and may cause an obstruction.
Figure 24: TAPP-training-model and right-side pelvic floor[55]

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  Results of Transabdominal Preperitoneal Patch Plasty Top

Between April 1993 and January 2008 in the surgical department (Marienhospital Stuttgart, Germany), 15 101 TAPP’s were performed by the first author and his team. All the cases were prospectively documented creating a huge data base. From time to time the results were analyzed, failures were discussed, and our practice changed accordingly, mainly due to an intensive study of the anatomy and especially of the fascial structures in the groin. This led to an increase of the dissection area and more precise dissection within the anatomic layers. Moreover, slitted and heavyweight meshes were deleted, the size of the meshes was enlarged (from 8 cm × 12 cm to 10 cm × 15 cm), traumatic fixation devices were avoided, and suture closure of the peritoneum was introduced. In summary, the following overall results (in total 17 surgeons were involved) could be achieved: Duration of operation: 40 min (12–276); morbidity: 2.5%; reoperation rate: 0.44%; and recurrence rate: 0.70%. With respect to various questions arising out of daily clinical treatment of inguinal hernias these results were confirmed and published in more than 35 high-ranking journals.

Furthermore, it should be emphasized that out of this huge patient pool a total of six randomized controlled studies (RCTs) were performed and published.[56],[57],[58],[59],[60],[61]

  Totally Extraperitoneal Patch Plasty Top

Patient positioning

In the TEP the patient positioning is like the TAPP. It is essential that the arms are at the patient’s side to allow enough room for the surgeon to stand at the side of the patient that is opposite the hernia. The arms should be protected to prevent nerve injury. If there are bilateral hernias, we suggest that the surgeon start with the more symptomatic hernia and switch sides after completing its dissection. The patient should be flat in slight Trendelenburg position.

Trocar placement

There are several accepted alternatives for trocar placement. The most common is the use of three trocars in the midline. The first trocar is placed at the level of the umbilicus, just off the midline to the side of the hernia to be repaired. The anterior rectus sheath is identified by retracting the fat with S-retractors. The fascia is incised with an eleven blade and the rectus muscle retracted laterally with the S-retractor to expose the posterior sheath. At this point, a balloon dilator can be inserted and slid down atop the posterior sheath until the pubis is palpated. Under direct vision from a zero-degree scope, the balloon is inflated to dissect the extra-peritoneal space. Care must be taken to not over inflate the balloon and to make sure it doesn’t slide below the pubis to avoid injury to the bladder. If the surgeon does not want to use the balloon, the scope itself can be used to dissect the extra-peritoneal space as Co2 is slowly instilled. This approach however takes longer and is more tedious. After an adequate extra-peritoneal dissection is achieved the second trocar (5 mm) is placed under direct vision a few centimeters below the 10 mm camera trocar and the third trocar is placed in the midline at least 2 cm superior to the pubis. Some surgeons place the third 5 mm trocar in a lateral position on the side of the hernia.

The second alternative is to use the technique popularized by Dulucq,[33] in which the dissection is begun by inserting a Verres needle at the pubis. Another variation is to do the extraperitoneal dissection after placing a 5 mm trocar intraperitoneal to evaluate the anatomy of the hernias and watch the extraperitoneal dissection as it is performed with an endoscope or balloon.[62] The final variation is to place the ports high in the abdomen to perform an ETEP as described by Jorge Daes.[63]


Once the trocars are placed and the initial extra-peritoneal space has been dissected, the dissection of the critical view of the Myopectineal Orifice as described by Daes and Felix in the Annals of Surgery.[64] There are seven steps that must be completed as in the TAPP repair before mesh can be placed to repair the hernia. The order of the steps can be varied according to the anatomy of the hernia and surgeon preference, but usually the medial dissection is carried out first to identify the pubis which is always a constant. The lateral dissection (area 1) is next, followed by the central dissection (area 3), with the indirect hernia, lipoma of the cord and parietalization of the cord.[65],[66]

The first seven steps to achieve the critical view of the myopectineal orifice

  1. Identify and dissect the pubic tubercle across the midline and CL. For large, direct hernias, extend the dissection to the contralateral CL [Figure 25].

  2. Rule out a direct hernia. Visualize anatomy through the inflated balloon during totally extraperitoneal and extended totally extraperitoneal repairs to detect a direct hernia before dissection. Remove unusual fat in the Hesselbach triangle [Figure 26].

  3. Dissect at least 2 cm between CL and the bladder to facilitate flat placement of the medial and inferior edge of mesh toward the space of Retzius, thereby avoiding mesh displacement caused by bladder distention [Figure 27].

  4. Dissect between CL and the iliac vein to identify the femoral orifice and rule out a femoral hernia [Figure 28].

  5. Dissect the indirect sac and peritoneum sufficiently to parietalize the cord’s elements. This step is often not completed, especially in a small surgical field. To ensure compliance with this requirement, continue to dissect until the cord’s elements lie flat. Then, visualize the psoas muscle and iliac vessels, pull the sac and peritoneum upward without triggering movement of the cord’s elements, and dissect between the cord’s elements to avoid missing a tail of the sac [Figure 29].

  6. Identify and reduce cord lipomas (which may appear small and unimportant until reduced). Usually lateral to the cord’s elements, they should not be confused with lymph nodes (which are generally spared). Most lipomas do not require removal but should be placed above the mesh to help prevent mesh rolling upward [Figure 30]A and B.

  7. Dissect peritoneum lateral to the cord’s elements laterally beyond the anterosuperior iliac spine (ASIS), sweeping it back cephalad well behind the mesh’s posterior border [Figure 31].
Figure 25: Showing step 1 with the dissection of the pubis (P) across the midline and the space of Retzius

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Figure 26: Showing step 2 with the dissection of the direct hernia (DH)

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Figure 27: Showing step 3 with the dissection of 2–3 cm below the pubis for future placement of the mesh

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Figure 28: Showing the reduction of a right femoral hernia (F) and the femoral defect (FD): step 4 in patients A and B

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Figure 29: Showing step 6: parietalization of the cord and reduction of the sac in an indirect hernia. The pubis (P), the testicular vessels (TV), and the vas deferens (VAS) are labeled

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Figure 30: (A and B) Showing the dissection of the lipoma of the cord (L) and the dotted line represents the location of the iliopubic tract

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Figure 31: Showing the TEP approach to step 7 using a two-handed spreading technique to fully dissect the peritoneum (P) laterally. The lateral cutaneous nerve (LCN) is seen covered by microfascia. The testicular vessels (TV) and vas deferens (VAS) are well visualized

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It is important to understand that the seven steps to complete the dissection for TEP are identical to the TAPP previously described but the initial technique or handling of the instruments varies slightly because the anatomy is not initially obvious as it is in the TAPP. It rather must be uncovered as the dissection is carried out. This makes the learning curve for the TEP longer and possibly steeper, but the TEP does have the advantage of not entering the peritoneal cavity thus avoiding some of the potential complications inherent in intra-peritoneal dissection. On the contrary, there are some circumstances when TAPP has definite advantages such as the incarcerated hernia or recurrent laparoscopic hernia. It is therefore important to the surgeon to pick the most appropriate MIS repair for the individual patient and surgeon expertise.

The final steps of the repair

  • 8. Complete the dissection to achieve the critical view of the MPO [Figure 32], provide mesh coverage, and ensure that mesh and mechanical fixation are placed well above an imaginary inter-ASIS line and any defects, thereby avoiding recurrence and nerve injury, especially to the ilioinguinal and iliohypogastric nerves [Figure 33].
    Figure 32: Showing step 8: Example of the completed dissection of the myopectineal orifice (MPO). The three hernia locations are labeled

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    Figure 33: Showing step 9 or placement of the mesh covering the entire MPO. The dotted line represents the imaginary inter-ASIS line. If penetrating fixation is used, it should be only placed above this line or in Cooper’s ligament

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  • 9. Place the mesh only when items 1–7 are completed, and hemostasis has been verified. Mesh size should be at least 15 cm × 10 cm, although a larger piece of mesh is sometimes required to cover the MPO. Preferably, choose mesh that adapts to the contour of the space and the cord’s elements. It should not have undue memory. Place it without creases or folds. Avoid splitting the mesh. Ensure that its later inferior corner lies deep against the wall and does not roll up during space deflation (use glue or careful suturing if necessary) [Figure 33].

The final two steps of the TEP repair are identifying that the first seven are complete and then placing the mesh with or without fixation. The mesh is placed through the camera port, advanced with the scope, and then manipulated into place. If at this point the surgeon finds that the landing zone dissection is not large enough to allow the mesh to lie flat without wrinkles and to be free of the peritoneal edge to avoid rolling up on deflation of the Co2, it is paramount that further dissection is performed. If penetrating fixation must be used sparingly and only well above the iliopubic tract and into CL. After mesh placement and any fixation, the gas is evacuated watching the peritoneum re-expand. If any portion of the mesh appears to become elevated by the release of the gas, further dissection of the space needs to be performed.

  Results of Totally Extraperitoneal Patch Plasty Top

Multiple studies have been published comparing the TEP and ETEP repairs to both open and TAPP repairs.[67] As stated previously there are advantages and disadvantages to the TEP when compared to both approaches, but the results according to recurrence in the hands of surgeons well trained in the approaches is essentially identical.[68] Choosing which approach to apply depends on surgeon expertise and the clinical presentation of the hernia. Many surgeons now feel however that the ETEP approach will allow surgeons to use the extraperitoneal approach in a wider variety of circumstances including larger scrotal hernias and cases where the space may be limited that were previously better performed with a TAPP approach.

The future

It has taken almost 30 years for MIS inguinal repairs to become accepted and possibly be viewed as the gold standard of inguinal hernia repair. Penetration of MIS repairs has only been 15%–25% depending on country or city of the surgeons, but with the advent of robotic TAPP repairs that penetration has grown rapidly. It has been reported to be approximately 50% in some areas in the USA. The sudden growth seems to be related to the ease of teaching the repair robotically and the shortening of the learning curve which has resulted in the adoption of the approach by surgeons previously resistant to MIS repairs. The major draw-back to R-TAPP initially was the cost and increase in operative time, but recent studies have shown that both impediments can be eliminated with experience as they were in the early days of the development of the TAPP and TEP approaches.

  Implementation of Laparoendoscopic Inguinal Hernia Repair in Daily Clinical Praxis Top

[Figure 34] shows a dramatic increase of scientific interests in diagnostics and treatment of inguinal hernia during the past three decades in close correlation with the advent of MIS.
Figure 34: Development of research in treatment of inguinal hernias

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Corresponding to a worldwide seen increase of the scientific activities shown in the figure, in Germany the frequency of laparoendoscopic inguinal hernia repair accelerated in the same remarkable way as the international research activities [Figure 35].
Figure 35: Paradigm change in inguinal hernia repair in Germany during the last three decades

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Up to the middle of the 80s nearly all of German patients suffering from an inguinal hernia were operated on according to the Bassini technique. Due to the influence of Volker Schumpelick during the late 80s the Shouldice repair was introduced in Germany and developed in the following years to the most frequently used technique applied in nearly 54% of the patients in 1992. However, in rapid succession after the advent of MIS, laparoendoscopic inguinal hernia repair attained more and more popularity, whereas Shouldice operation dropped down. Currently, the data of the National Office for Statistics Wiesbaden 2019 show that in Germany nearly 67% of the in-hospital inguinal hernia repairs are performed laparo-endoscopically, but only less than 4% in Shouldice technique [Figure 35]. Notably, this dramatic increase is mainly due to the greater acceptance of the TAPP technique, whereas TEP remains constantly between 18% and 20.9% [Figure 36]. I believe, that the reason for this different development of both of the MIS methods maybe that TAPP is easier to perform, especially for beginner, and has a broader indication spectrum in comparison to TEP, however, there is no scientifically founded explanation. Experience from other countries or continents in which TEP is the predominant repair shows that the influence of specific surgical personalities and tradition may also play an important role.
Figure 36: Development of TAPP and TEP in Germany during the last 10 years

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Although in Germany the penetration rate of laparoendoscopic inguinal hernia repair is relatively high, worldwide there are significant differences between continents and countries as well [Table 1]. Furthermore, in some countries there are huge differences between cities and rural regions (Russia), between different provinces (Spain), between different hospitals or surgeons (Slovenia, Indonesia), and between public and private hospitals (Mexico, HongKong, France). A recently published paper from Spain analyzed multiple factors which may influence the penetration rate of laparoendoscopic inguinal hernia repair in detail.[69] Guillaumes et al.[69] defined the factors associated with the choice of laparoscopic approach in a population-based study of 263,283 patients. The authors found on multivariate logistic regression analysis, the patient place of residence, with other words the specific surgeon, is the most important factor associated with the likelihood of receiving LAP-IHR (OR 4.96; P < 0.001). In decreasing significance the authors found further factors favoring LAP-IHR, for example, bilateral operation (OR 4.596; P < 0.001), insurance coverage (OR 4.439; P < 0.001) and self-pay patients (OR 2.317; P < 0.001), as well as a recurrent hernia (OR 1.780; P < 0.001), age younger than 65 years (OR 1.555; P < 0.001), and male sex (OR 1.162; P < 0.001). Out of the unilateral hernia group, only 4.3% were operated laparo-endoscopically, whereas in the bilateral group this percentage was 17.5%, thus more than four times higher. In the UK a similar situation can be observed, only 19.4% of the patients with a unilateral hernia are operated laparoendoscopically, but 67.7% of the bilateral. Furthermore, in Spain a significant difference between public and private hospitals, 4.3% vs. 16.1% was found. With respect to primary or recurrent hernia the percentages were 5.6% vs. 8.0%. Interestingly, in Spain the MIS-technique was more applied in males (5.8%) than in females (4.9%). However in Sweden about 50% of the female patients are operated on laparoscopically, and in male patients the percentage was only 23%. The reason for this remarkable difference might be that the Swedish surgeons are more willing to follow the guidelines[4],[36] compared to the Spanish surgeons. Regarding insurance coverage the Spanish data are confirmed by the France statistics (personal communication Jean Francois Gillion and Hubert Johanet), but on an essentially higher penetration level: currently in public hospital in France the MIS percentage is 34.7%, in private hospitals 52.3%, and Club Hernia institutions 63.5%. Like in Spain in many countries the place of residence of the patients and the specific hospital are of paramount importance for being operated in open or laparoendoscopic technique [Table 1], for example, in Russia the overall penetration rate is about 10%–12%; however, in the capitals Moscow and St. Petersburg this rate reaches 53%. In Slovenia the overall penetration rate is about 25%; however, in some hospitals the rate is less than 10%, but in other but few hospitals excels 50%. Confirming the Spanish study, a study from Canada concludes that “The surgeon was by far the most important predictor of the use of a laparoscopic approach”[70] rather than the indication appropriateness. In the same study the authors claim that lack of educational facilities may also be an important factor for a reluctant adaption of MIS in hernia repair. In their inquiry Trevisonno et al.[70] found that about 30% of the residents would be willing to learn but have no possibilities; thus, education is a further key factor, but not to forget the personal interest of the surgeon in hernia repair. The penetration rate in Poland shows that although the overall national frequency of laparoendoscopic hernia repair is only about 10%–12%, but surgeons participating in hernia meetings used this technique in about 30% of their patients. Last but not least in the line of the discussed reasons above, it must be emphasized the lack of financial resources in by far most parts of the world as well as badly organized health care systems and insufficient reimbursement. Admittedly, if you start laparoscopic hernia repair you need a first capital investment of €50,000–100,000 for video tower and instruments. This is no problem if you are working in a hospital or if you operate on a high case volume, because in a hospital the expensive video tower is used for many other procedures, for example, cholecystectomy, thus the high primary cost will rapidly being redeemed. Around the world there are still a countless number of hospitals that are not in the financial situation to afford modern medical equipment.
Table 1: Penetration rate of laparoendoscopic inguinal hernia repair worldwide

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In summary, despite 30 years of experience with laparoendoscopic inguinal hernia repair and publication of countless studies, systematic reviews and meta-analyses, which clearly show that TAPP and TEP have similarly low recurrence rates and are significantly superior to open mesh repair with respect to all pain-related parameters[43] and despite the recommendation of the recently published International Guidelines “for male patients with primary unilateral inguinal hernia, a laparo-endoscopic technique because of a lower postoperative pain incidence and a reduction in chronic pain incidence, provided that the surgeon with specific expertise and sufficient resources is available,”[4] the overall worldwide acceptance rate is still remarkable low [Table 1]. One aspect which very often is not adequately discussed is related to the cost-efficiency of laparo-endoscopic inguinal hernia repair compared to open surgery. Due to less pain the patient is able to return to work earlier. In Germany per year about 210,000 inguinal hernia repairs are performed (in-hospital 177,000, praxis round 33,000). In Germany, one day of disability of work of a workman means a loss of about 200 € to the economic system. Thus, assuming that about 100,000 patients of the total population are still included in the working process, and who are able to return to work after minimal invasive surgery one day earlier compared to open repair, this would mean that about €20 million could be saved per year.

In summary, despite a dramatic increase of the frequency of laparoendoscopic inguinal hernia repair during the last years in many countries, the overall penetration rate is still disappointing. The main reasons for the reluctant adaption of the new patient-friendly technique are above all surgeon-related, but also related to economical resources of some national health care systems, lack of systematic educational programs as well as absence of strong protagonists. What to do?

In Germany, in 1998 the frequency of laparoendoscopic inguinal hernia repair was 33.5%; currently, it is 63.3%. Milestones in this development are as follows:

  1. In 2000 foundation of the sub-society “Minimal Invasive Surgery” belonging to the German Society for General- and Visceral Surgery by two protagonists of laparo-endoscopic hernia repair (Reinhard Bittner, Ferdinand Köckeling).

  2. In 2002 foundation of the German Hernia Society by Volker Schumpelick (President) and Reinhard Bittner (Vicepresident). The most important resolution, meeting president one year should be an open and the next year a laparoscopic surgeon. After 7 years this rule could be abandoned because all did open and laparoendoscopic surgery.

  3. In 2004 foundation of the International Endohernia Society (IEHS) by Reinhard Bittner and Ferdinand Köckerling.

  4. Seit 2007 German Hernia Days Berlin/Hamburg/Köln (Ralph Lorenz, Wolfgang Reinpold, Bernd Stechemesser).

  5. In 2009 foundation of the “Herniamed“ registry (Ferdinand Köckerling) with a scientific meeting every year.

  6. Since 2011 yearly one three-days educational meeting “Hernia Compact” for 50 trainees in surgery inclusive cadaver operations, training at models and attending life surgery.

  7. Since 1991 countless meetings and courses (e.g., MIC-Symposium Hamburg, Masterclass Courses Association of German Surgeons in Berlin) with life demonstration of laparoendoscopic hernia repair. Not only because of these manifold activities but also because many publications, reporting the results of specific scientific studies as well as the “real life” data documented in the “Herniamed” registry, which meanwhile includes nearly 800,000 Patients, the majority of the German surgeon could be convinced to adapt the minimal invasive operative technique in inguinal hernia repair.

  Conclusion and Future Perspectives Top

Inguinal hernia repair is not a very spectacular operation; however, due to the tremendous number of patients worldwide this disease has a significant impact not only for the patient but also for the health-care system of each country. A cost-effective as well a cost-efficient repair is therefore of paramount importance. In countless studies, it could be shown that regarding cost-efficiency the minimally invasive techniques are superior to open repair. About three decades after introduction in clinical praxis TAPP and TEP are easy to perform, absolutely reproducible, safe, and effective, and can be done with low costs. Nevertheless, the penetration rate in many countries is inadequately low. The reasons for this depressing reality are extensively discussed in this article. It is highly questionable if new techniques like robot-assisted laparoscopic technique will essentially be able to promote at least TAPP. The data from the US may encourage; however, the financial situation of the US patients is not comparable to the rest of the world. Without any doubt, robot-assisted inguinal hernia repair is safe and can be adapted in a reasonable short time.[71],[72],[73],[74] The ergonomic advantages for the surgeon are undisputed. The main drawbacks are still higher costs[75],[76] and longer operation times. The conclusion of the only RCT which is published up to now is rather depressing:[71]

“Results of this study showed no clinical benefit to the robotic approach to straight forward inguinal hernia repair compared with the laparoscopic approach. The robotic approach incurred higher costs and more operative time compared with the laparoscopic approach, with added surgeon frustration and no ergonomic benefit to surgeons.”

A detailed cost analysis done by Charles et al.[76] estimated incremental costs for the robot surgery in inguinal hernia of about 2,500 USD. Maybe in future, the cost for the robot will come down, however, at the current juncture robot surgery should be restricted to centers in order to precisely evaluate the benefits in terms of cost-efficiency. It is quite conceivable that already now that complex hernias like large inguinoscrotal hernias may be better operated with the assist of the robot. However, to prove the benefits properly conducted trials are urgently needed.


Many thanks to all of the colleagues who informed me about the penetration rate of laparoendoscopic inguinal hernia repair in their countries: Abolmasov A, Agresta F, Antonov A, Arregui M, Berrevoet F, Bisgaard T, Bowker A, Campanelli G, Chowbey P, Daes J, Dedemadi G, Felix EL, Fortelny R, Gillion JF, Goek H, Gonzalez JCM, Gorjanc J, Hachisuka T, Johanet H, Kukleta J, Lomanto D, Misra M, Mjåland O, Montgomery A, Morales-Conde S, Smietanski M, Qin Ch, Roberts R, Santilli O, Simons M, Smart N, Soltes M, Strupas K, Udomsawaengsup S, Tran H, Vironen J, and Yang G.

Financial support and sponsorship


Conflicts of interest

Prof. Reinhard R. Bittner is an Editor-in-Chief of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal’s standard procedures, with peer review handled independently of this Editor-in-Chief and their research groups.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32], [Figure 33], [Figure 34], [Figure 35], [Figure 36]

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