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Table of Contents
Year : 2018  |  Volume : 1  |  Issue : 3  |  Page : 69-73

A case for open inguinal hernia repair

Department of Surgery, Chatham-Kent Health Alliance, Chatham, Ontario, Canada

Date of Submission18-Jul-2018
Date of Acceptance30-Aug-2018
Date of Web Publication19-Nov-2018

Correspondence Address:
Dr. John Morrison
78 Victoria Ave, Chatham, Ontario N7l 3A1
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_17_18

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The open approach to inguinal hernia repair has several distinct advantages in the management of both primary and recurrent groin hernia repairs. A variety of repair techniques are available to suite the patient's condition. Both pure tissue and mesh techniques in a tailored fashion may be employed, rather than the cookie-cutter approach where the mesh is used in the same fashion in every case. Most patients with preexisting comorbidities may have repair carried out under local or regional anesthesia instead of general anesthesia as required by laparoscopy. Studies have demonstrated the efficacy of open preperitoneal mesh placement in the treatment of recurrent inguinal and femoral hernia repair, where hernia recurrence rates, postoperative complications, and long-term patient outcomes are equivalent to laparoscopic repair. The use of robots has yet to demonstrate any advantage over manual repairs either open or laparoscopic, with extended operating time and extreme cost. Return to normal daily activity is advocated in 3–7 days whichever technique is used.

Keywords: Laparoscopic inguinal hernia repair, open inguinal hernia repair, preperitoneal approach

How to cite this article:
Morrison J. A case for open inguinal hernia repair. Int J Abdom Wall Hernia Surg 2018;1:69-73

How to cite this URL:
Morrison J. A case for open inguinal hernia repair. Int J Abdom Wall Hernia Surg [serial online] 2018 [cited 2022 Sep 27];1:69-73. Available from: http://www.herniasurgeryjournal.org/text.asp?2018/1/3/69/245592

  Introduction Top

Inguinal hernia repair represents one of the most common operations performed by the general surgeon worldwide. The lifetime risk to develop an inguinal hernia is 27%–43% for men and 3%–6% for women.[1] In the USA and Canada, almost one million procedures are performed annually, while almost twenty million are performed worldwide. With the introduction of the Lichtenstein tension-free repair,[2] the use of polypropylene mesh has now become the most common method of repair by open technique.[3],[4],[5]

Pure tissue-suture repair is still widely practiced in the developing world where the cost of mesh is prohibitive. The use of flat mesh has now superseded the older pure tissue-suture repairs such as Shouldice, Bassini, and McVay. These pure tissue repair techniques still have their place in the surgeon's armamentarium and should be taught to surgical residents by staff experienced in their use. In the current climate of litigation, patient demand for pure tissue/suture repair is increasing and should be considered by those involved in both the practice and teaching of hernia surgery.

The learning curve associated with open primary inguinal hernia repair is short when there is good knowledge of the groin anatomy, while the learning curve for laparoscopic repair has been reported as being a minimum of 65–80 cases[6],[7],[8] and an ongoing case volume of at least 30 cases annually. For many general surgeons, this is beyond the number of hernia repairs they would normally carry out.

Since its introduction as initially described by Ger et al.,[9] Arregui et al.,[10] and Dulucq,[11] the laparoscopic approach to inguinal hernia repair has failed to fulfill its early promise of becoming the standard repair. This is in sharp contrast to laparoscopic cholecystectomy which has become the gold standard in the treatment of gallbladder disease. Apart from the localized centers of expertise, <20% of inguinal hernias are repaired laparoscopically worldwide. These numbers may be due to lack of equipment, training, cost, or the learning curve. Preceptors may not be available locally to guide the learning surgeon.

In early publications, the laparoscopic technique has been shown to be a viable and sustainable procedure with excellent patient outcomes even when carried out in a small community hospital.[12],[13] So why is the rate of laparoscopic hernia repair so low?

The international guidelines suggest that the laparoscopic approach should be employed for recurrent groin hernias, previously repaired anteriorly, and for all groin hernias in women.[14],[15] Is there an advantage to these recommendations, or can the open anterior approach fulfill the patient's needs?

Recently, robotic inguinal hernia repair has been introduced with some fanfare associated with the enormous capital and operational cost. It is yet to be shown if this technology has any significant benefit for the patient in the long or short term, Is it possible that robotic surgery is being used as a sales gimmick to generate patient numbers? This has yet to be established.

This paper attempts to compare the various techniques and repair modalities in terms of patient outcome with a personal viewpoint following a surgical career of more than 40 years.

  Methods Top

A search was made of the PubMed and Cochran Databases, employing the search terms “Open Inguinal Hernia Repair,” “Laparoscopic Inguinal hernia Repair,” and “Robotic Inguinal Hernia Repair.” A total of 6406 references were found. From this database, 96 full-text articles published in the past 5 years were examined. This vast number of papers published on a relatively narrow surgical topic indicates the depth of discussion underway, concerning the various repair modalities, current results, and outcomes.

In laparoscopic repair, TAPP and TEP were regarded as a single procedure, while open hernia repair was divided into “suture/pure tissue” and “mesh” techniques. Full review was carried out of papers considered appropriate to provide a range of opinions toward the endpoint. Anterior and open preperitoneal mesh placements are discussed, and are compared to the laparoscopic approaches, while robotic surgery is treated as a separate entity.

  Results Top

In Europe, it has been reported that of 830,000 inguinal hernia repairs in 2014, 23% were laparoscopic procedures.[16] In Poland, it has been reported that 13.3% of females undergo laparoscopic repair,[17] while in Australia, it has been reported that 43% of adult patients undergo laparoscopic repair.[18] This is also echoed by reports from Switzerland of 41.5% laparoscopic repairs[19] and in Finland 25%.[20] In Canada, of 49,657 patients undergoing inguinal hernia repair, only 8% had laparoscopic repair.[21]

Two large series of patients undergoing primary open pure tissue repair were included. A series of 65,127 patients who underwent open repair at the Shouldice Hospital, whose outcome in terms of hernia recurrence has been described by Urbach.[22] The Shouldice repair was equivalent if not superior to laparoscopic repair with a 1.1% recurrence rate.

A second series from the German Database HerniaMed with propensity score matching compares a series of 2608 patients repaired by the Shouldice technique, with 22,111 patients undergoing a Lichtenstein procedure, 14,559 patients undergoing TEP, and 21,236 patients undergoing TAPP.[14] The Shouldice repair was found to be equivalent in terms of achieving an outcome comparable to that of Lichtenstein.[23]

The open preperitoneal approach as originally described by Nyhus et al. in a series of 195 patients undergoing repair is included.[24] With up to 10-year follow-up, preperitoneal mesh placement was found to be superior to tissue/suture repair.

In a prospective series of 107 patients by Yang et al., undergoing repair of a recurrent inguinal hernia using the open preperitoneal technique with a mean follow-up time of 42.3 months, there were three hernia recurrences in the series with an overall complication rate of 8.4%.[25]

A retrospective series of 249 patients carried out by Liu et al. comparing the open preperitoneal approach with Lichtenstein showed earlier mobility in the open preperitoneal group than the Lichtenstein, lower visual analog scale sore in the preperitoneal group, with no significant cost difference. Follow-up was for a period of up to 36 months, without hernia recurrence.[26]

In the obese patient, a series by Froylich et al. of 7346 patients were included in a study, where 5573 patients underwent laparoscopic inguinal hernia repair, while 1773 underwent open inguinal hernia repair. Postoperative outcomes were adjusted by propensity scoring. Outcomes were similar with regard to 30-day wound events.[27]

A further study by Sajid et al. included a collection of 10 randomized trials incorporating 1286 patients comparing laparoscopic versus open preperitoneal mesh repair. They concluded that both techniques were equivalent in terms of recurrence, groin pain, and postoperative complications.[28]

A publication by Li et al. included 1760 patients and compared laparoscopic repair with open preperitoneal repair. Both techniques were safe and effective, with laparoscopic repair having significantly fewer wound infections and chronic pain.[29]

A meta-analysis by Li et al., including 1311 patients in six randomized controlled trials, showed less wound infection rates and faster recovery in laparoscopic procedures. Other complication rates including recurrence rate were comparable.[30]

  Discussion Top

The most common operation performed today in inguinal hernia repair is the open anterior approach with or without the use of mesh. The anterior approach may be carried out under local, regional, or general anesthesia, as compared to the laparoscopic and robotic techniques which employ general anesthesia. This may not be appropriate for patients with preexisting comorbidities.

The open approach gives full access to both the posterior wall of the inguinal canal, and on opening the transversalis fascia, complete access to the preperitoneal space as described by Fruchaud.[31] This immediately provides access to the femoral canal. With access to these spaces under direct vision, the surgeon has the choice of several repairs which may be carried out as opposed to being limited to the placement of mesh in the preperitoneal space only, as used in laparoscopic techniques. Interestingly, HerniaSurge International Guidelines have been modified in 2018 to recommend not using mesh plugs, PHS system, and other 3-dimensional devices.[32]

Open primary repair

For any inguinal hernia repair to be successful, the surgeon must have intimate knowledge of the groin anatomy and its major variations. The course of the nerves lying within the floor of the inguinal canal should be identified at the time of surgery to prevent injury.[16] However, many of these nerves have a very variable anatomy, and dissection to search for them may in fact cause injury.[33]

Open repair may be carried out under local, regional, or general anesthesia. Shouldice repair has been shown to be the best pure tissue technique and when carried out in the correct manner, comparing very favorably with the recurrence rates of mesh repair,[22] both open and laparoscopic. The Lichtenstein technique is the most widely used and being easily taught to residents, with recurrence rates of 1%–2%, while pure tissue repair often requires much more detailed anatomical knowledge for successful repair. Carried out correctly, the Shouldice repair provides essentially the same recurrence rate. Unfortunately, education in the various pure tissue repair techniques is lacking.

Laparoscopic repair of a primary inguinal hernia again involves detailed anatomical knowledge of the pelvic floor anatomy, especially the course of the major blood vessels, the spermatic cord, and the groin nerves. This type of repair involves placement of mesh in the preperitoneal space either through the abdomen (TAPP) of totally extra-peritoneal (TEP). Mesh and general anesthesia must be used in all cases of laparoscopic groin hernia repair now. The results of laparoscopic repair show less rates of wound infection, earlier return to normal activities, and a recurrence rate comparable to other repair methods.

Open preperitoneal approach for primary and recurrent inguinal hernia repair

This procedure can be much more daunting for many general surgeons. In these cases, knowledge of the groin anatomy is vital as tissues and planes may have been changed or eliminated by previous surgery in open preperitoneal repair as described by Nyhus. He advised that sutures rather than tacks should be placed under direct vision to prevent nerve damage. Mesh that has been used in an earlier repair may require removal to provide full access to the recurrence for further repair. In many of these cases, repair can easily be carried out by placing flat mesh in the preperitoneal space by incising the transversalis fascia and dissecting out the preperitoneal space to display the entire myofascial plane. This is very similar to the laparoscopic technique of mesh placement without the requirement of specialized equipment, laparoendoscopic knowledge, or cost. Open placement of preperitoneal mesh may also be employed for the treatment of primary inguinal hernias and has the advantage of being able to examine the femoral canal at the same time. The results of open preperitoneal mesh placement have been shown to be equivalent to laparoscopy including patient discomfort and recurrences.

Open femoral hernia repair

Femoral hernias occur in about 5% of women and 1% in men. A concomitant femoral hernia can be easily missed unless the preperitoneal space is opened and the femoral canal examined. This may account for some femoral hernia recurrences following open anterior repair.[33] The open approach has been the standard technique for repair until the international guidelines recommended the laparoscopic approach, especially in women.[14],[15] However, the femoral canal is just as easily accessible through an open preperitoneal approach, and hernias in this location can be easily treated with preperitoneal flat mesh. Mesh plugs in the groin and femoral canal should be avoided.[32] The results of open femoral hernia repair again compare favorably with laparoscopic repair. In women, the tailored approach is often advisable, as many lateral hernias may not require a mesh repair.

Patient outcomes

Ultimately, all surgical procedures must be measured in terms of patient outcome. It is frequently stated that laparoscopy is associated with better cosmesis, less patient discomfort, and earlier return to normal activities. This may be true for the first several days postoperatively. For self-employed patients, most return to work within 48 h of surgery, while manual workers take significantly more time away from work no matter which technique is employed. When to return to work has long been a topic of discussion with few studies published. However, more recent recommendations advise patients to return to normal daily activities within 3–7 days.[13],[34],[35]

  Conclusions Top

The open anterior approach to inguinal hernia repair has several distinct advantages over the laparoscopic approach. The open repair of groin hernias may be tailored to the patient's specific hernia condition, rather than a single utilitarian approach offered by laparoscopic repair. The open approach provides the surgeon with multiple choices of repair techniques both mesh and pure tissue. Most patients can be treated by open repair despite their preexisting medical comorbidities, which may preclude the general anesthesia necessary for laparoscopic repair. The open repair requires the surgeon to have intimate knowledge of the groin anatomy to provide the most suitable repair for the patient in a tailored approach. Open preperitoneal mesh repair can readily be carried out for the treatment of recurrent inguinal and femoral hernias in addition to the treatment of primary hernias with results equivalent to laparoscopic repair.

Robotic inguinal hernia repair has been shown to take longer to perform, is associated with astronomically increased capital cost, and yet, has shown no patient benefit over laparoscopic or open repair.[36],[37],[38],[39],[40]

The long-term results of correctly performed anterior repair are not different from those carried out laparoscopically. Who can truly call themselves a “hernia surgeon” when they cannot perform a proper pure tissue/suture repair?

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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