Laparoscopic inguinal hernia repair - Lessons learned after 1224 consecutive cases

Background: Despite numerous attempts to improve the techniques used for he rnia repair, current published series show that recurrence rates are as hig h as 5-20%. The complexity of inguinal anatomy, combined with multiple pote ntial areas of weakness, has contributed to the difficulty in preventing re currences. However, the laparoscopic approach to inguinal herniorrhaphy has allowed clear visualization of all preperitoneal fascial planes and anatom ic landmarks, as well as the hernia defect(s) and the peritoneal reflection . In the course of our performance of a series of 1,224 laparoscopic inguin al hernia repairs, we have developed a total extraperitoneal approach that yields excellent results with a low initial recurrence rate. Herein we desc ribe our experience. Methods: After our initial 300 transabdominal preperitoneal (TAPP) hernia r epairs, which resulted in six recurrences, two bowel injuries, one bladder injury, and six cutaneous nerve injuries, the total extraperitoneal approac h (TEP) was adopted. Results: The first 300 TEP repairs resulted in one recurrence, two bowel in juries, one bladder injury, and two cutaneous nerve injuries. All major com plications occurred in patients who had had previous lower abdominal surger y. In the last 624 TEP herniorrhaphies we implemented some modifications to the technique, especially for patients with previous lower abdominal surge ry. In this group we recorded one bladder injury, no cutaneous nerve injuri es, and one recurrence. Conclusions: The total extraperitoneal approach for laparoscopic herniorrha phy allows for a safe and effective repair with low rates of complication a nd recurrence. A thorough knowledge of the anatomy of the extraperitoneal s pace and especially the two- and three-dimensional inguinal anatomy of this space contributed greatly to the evolution of our technique.