Laparoscopic repair

Laparoscopic inguinal hernia repair is often referred to as “minimally invasive”.

“Minimal access” is probably a better term because although the 2 or 3 access or entry holes are small a lot is done inside – the operation itself is still pretty “invasive“. Like painting your hallway through the letter box. You can do a lot of damage if you don’t do it right.

This type of surgery has to be carried out under a full general anaesthetic. Between two and four small incisions are made in the skin so that instruments and a camera can be inserted into the abdomen.

The abdominal cavity is then inflated with a gas (carbon dioxide) to give the surgeon space to work inside the patient.

The camera has a light that gives the surgeon a view from the inside that he / she watches on a television screen and the actual operating is done ‘remotely’ with long instruments which have been passed through the other holes or entry ports.

Comparison between open ‘Lichtenstein’ and laparoscopic ‘TEP’ repairs.

An analysis (metanalysis) of 13 trials and over 3,000 patients

The advantage for laparoscopic surgery in general is that no large cut is made on the abdomen, so in theory there should be less pain immediately after the operation and a quicker return to normal activities.

So for major bowel surgery, where large cuts have traditionally been made, the laparoscopic option is a good one. But for inguinal hernia repair the cut for the open local anaesthetic repair is small anyway, so the difference is not that significant.

In practice you can get quite a lot of pain after a laparoscopic inguinal hernia repair because the deep tissues have been cut and pulled, and also staples may have been used to fix the mesh.

However when done well, by properly trained experienced surgeons, in appropriately selected cases the results of keyhole inguinal hernia repair can be excellent.

What are the disadvantages of the keyhole repair?

You have to have a general anaesthetic. Not so good if you are elderly or have other medical conditions
It is technically demanding. What that really means is that it is difficult to learn and difficult to do well. There is what surgeons euphemistically call a ‘learning curve’.
You have to practice a lot and do a lot (how much is “a lot”?*) to get good at it, and will make mistakes during that earning curve.
The chance of a recurrence – the hernia coming back – is slightly higher than after an open repair
There is the risk of major organ damage – blood vessel, bowel and bladder

* How much is “a lot”? – I think you want your surgeon have to have carried out at least 500 laparoscopic hernia repairs. I know if I was having one of these operations I would want my surgeon to have carried out that sort of number. See d) below.

Situations when laparoscopic inguinal hernia repair is a good option

When and where there has been a previous failed open repair, particularly if mesh was used
If there is an inguinal hernia on both sides – left and right (bilateral) – and both are to be repaired at the same time
In fit, fully informed patients operated on by an experienced laparoscopic surgeon

NICE * has made the following recommendations about the use of laparoscopic surgery to treat inguinal hernia – 2004  http://guidance.nice.org.uk/TA83

“Laparoscopic surgery can be used as an option for repairing inguinal hernia. As with all surgery, there are some risks involved, which may include serious problems just after the operation….   In helping you make this decision you and your doctor should particularly consider:   

a) how well you are likely to cope with a general anaesthetic  

b) whether this is your first hernia, or whether it has come back or affects both sides of the groin  

c) whether an open or keyhole operation would work best for your particular hernia d

d) how much experience the surgeon has in the technique.”

* NICE is the National Institute for Clinical Excellence, an organisation set up to provides national guidance and advice to improve health and social care.