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> Laparoscopic totally extraperitoneal inguinal hernia repair : lessons learned from 3,100 hernia repairs over 15 years

Background : Two revolutions in inguinal hernia repair surgery have occurred during the last two decades. The first was the introduction of tension-free hernia repair by Liechtenstein in 1989 and the second was the application of laparoscopic surgery to the treatment of inguinal hernia in the early 1990s. The purposes of this study were to assess the safety and effectiveness of laparoscopic totally extra-peritoneal (TEP) repair and to discuss the technical changes that we faced on the basis of our accumulative experience. Methods Patients who underwent an elective inguinal hernia repair at the Department of Abdominal Surgery at the Institute of Laparoscopic Surgery (ILS), Bordeaux, between June 1990 and May 2005 were enrolled retro- spectively in this study. Patient demographic data, operative and postoperative course, and outpatient follow-up were studied.

Results : A total of 3,100 hernia repairs were included in the study. The majority of the hernias were repaired by TEP technique ; the repair was done by transabdominal preperitoneal (TAPP) repair in only 3%. Eleven percent of the hernias were recurrences after conventional repair.

Mean operative time was 17 min in unilateral hernia and 24 min in bilateral hernia. There were 36 hernias (1.2%) that required conversion : 12 hernias were converted to open anterior Liechtenstein and 24 to laparoscopic TAPP technique. The incidence of intraoperative complications was low. Most of the patients were discharged at the second day of the surgery. The overall postoperative morbidity rate was 2.2%. The incidence of recurrence rate was 0.35%. The recurrence rate for the first 200 repairs was 2.5%, but it decreased to 0.47% for the subsequent 1,254 hernia repairs

Conclusion : According to our experience, in the hands of experienced laparoscopic surgeons, laparoscopic hernia repair seems to be the favored approach for most types of inguinal hernias. TEP is preferred over TAPP as the peri-toneum is not violated and there are fewer intra-abdominal complications.

Keywords : Inguinal hernia, Totally extra peritoneal repair, Laparoscopic repair, 3-D mesh

Hernia repair is the most frequently performed operation in general surgery. Since Bassini’s report of inguinal hernia cure in 1887 [1], numerous other techniques have been described. During the first half of the 20th century, repairs were based on bringing together and suturing the edges of the defect. These techniques resulted in high recurrence rates and postoperative morbidity due to the tension on the suture lines.

Two revolutions in inguinal hernia repair surgery have occurred during the last two decades. The first was the introduction of tension-free hernia repair by Lichtenstein in 1989, which significantly reduced recurrence rates [2].

Jean-Louis Dulucq

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