Laparoscopic herniorrhaphy

With the introduction of laparoscopic cholecystectomy, the general surgery community was introduced to the world of minimally invasive surgery. In less than two years, just about every meeting, journal, and medical trade show demonstrated this "new" found technique. Surgeons have been very quick to pick up on the laparoscopic technique, and have actively sought other applications for the laparoscopic approach. With approximately 400,000 inguinal hernia repairs being performed in the United States annually, I the laparoscopic repair of this common malady was very quickly embraced as a possible new application. The concept of a trans-abdominal repair of a hernia defect is not new, having been described as early as the original description of "the modem day" hernia repair by Marcey. A trans-abdominallaparoscopic repair has a potential advantage over a conventional groin approach by it's avoidance of the groin incision and the need to mobilize the cord structures. This not 'only minimizes post operative pain, but also the risk of long term morbidity.related to mobilization of the cord. (neuroma formation secondary to injury of the cutaneous nerves, epididymitis and orchitis) There is also the possible advantage of an earlier return to normal activities. In contrast to laparoscopic cholecystectomy, there are technical differences between the laparoscopic and open hernia repairs. This difference raises the question as to whether or not the laparoscopic repair will yield results that will compare with an open technique. Open surgical techniques are considered a safe and effective means of treating inguinal hernias. The operation avoids the violation of the abdominal cavity, can be performed under local anesthesia, and is often performed on an outpatient basis. This raises the question "why via the laparoscope"? Despite reports from specialized hernia centers reporting a recurrence rate of 0 to 2 percent, large series from community based surgeons continue to report recurrence rates in the range of 5 to 10 percent. This recurrence rate has changed very little since Bassini reported a recurrence rate of 10 percent at the turn of the century. Although the overall morbidity of an open repair is only in the range of 2 percent, this morbidity .consists almost entirely of complications related to the wound and mobilization of the cord structures. The standard open hernia repair is not a perfect operation, and any attempt at its improvement is warranted. Since the laparoscopic repairs approaches the defect from within avoiding a large surgical incision and mobilization of the cord structures, the repair logically makes sense. Despite the intuitive advantages of the laparoscopic repair, questions regarding recurrence rates and safety of the laparoscopic repair still need to be answered.