“A COMPARATIVE STUDY OF

LICHTESTEIN OPEN TENSION-

FREE VERSUS LAPROSCOPIC
TOTALLY EXTRAPERTIONEAL
TECHNIQUE FOR INGUINAL HERNIA
REPAIR”

Dissertation
Submitted to the
Rajasthan University of Health Sciences, Jaipur
For the degree of
M.S. (General Surgery)
2015

Submitted by:
Dr.BADRI NARAYAN SHARMA

Under the Supervision and Guidance of:

Dr. Rajendra Mandia
PROFESSOR AND UNIT HEAD
UPGRADED DEPARTMENT OF GENERAL SURGERY
S.M.S. MEDICAL AND HOSPITAL
JAIPUR (RAJASTHAN)
Rajasthan University Of Health Sciences
Jaipur,Rajasthan

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis

entitled “A COMPARATIVE STUDY OF
LICHTESTEIN’S OPEN TENSION-FREE
VERSUS LAPROSCOPIC TOTALLY
EXTRAPERTIONEAL TECHNIQUES FOR
INGUINAL HERNIA REPAIR” is a bonafide
and genuine research work carried out by
me under the guidance of Dr.Rajendra
mandia, Professor, Department of
General Surgery, S.M.S. Medical College
Jaipur.

Date : Signature Of
Candidate
Place : Jaipur
Dr. Badri
Narayan Sharma

Rajasthan University Of Health Sciences

Jaipur,Rajasthan

DECLARATION BY THE GUIDE

I hereby declare that this dissertation/thesis
entitled “A COMPARATIVE STUDY OF
LICHTESTEIN’S OPEN TENSION-FREE
VERSUS LAPROSCOPIC TOTALLY
EXTRAPERTIONEAL TECHNIQUES FOR
INGUINAL HERNIA REPAIR” is a bonafide
research work done by Dr. Badri Narayan
Sharma in partial fulfilment of the requirement
for the degree of M.S. in General Surgery.
Date : Signature Of The
Guide
Place : Jaipur
 Dr. Rajendra
Mandia
Prof. Department Of
Surgery S.M.S. Medical
College Jaipur.

Rajasthan University Of Health Sciences

Jaipur,Rajasthan
ENDORCEMENT BY THE HOD
PRINCIPAL/
HEAD OF THE INSTITUTION
This is to certify that dissertation entitled “A
COMPARATIVE STUDY OF LICHTESTEIN’S OPEN TENSION-
FREE VERSUS LAPROSCOPIC TOTALLY EXTRAPERTIONEAL
TECHNIQUES FOR INGUINAL HERNIA REPAIR”is a bonafide
research work done by Dr.Badri Narayan Sharma under the
guidance of Dr.Rajendra mandia,Professor,
Department of General Surgery, S.M.S. Medical College
Jaipur.

Seal & Signature of the HOD Seal & Signature of

the Principal
Dr.R.K.Jenaw Dr.Subhash Nepalia
M.S. D.M.
Prof.and Head Of Dean and Principal
Department Of Surgery S.M.S. Medical
College,
S.M.S. Medical College,Jaipur Jaipur

Date :
Place : Jaipur

Rajasthan University Of Health Sciences

Jaipur,Rajasthan

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajasthan

University Of Health And Sciences, Jaipur,
Rajasthan Shall have the rights to Preserve
, use and disseminate this
dissertation/thesis in print or electronic
format for academic/research purpose.

Date : Signature Of
Candidate
Place : Jaipur
Dr. Badri Narayan
Sharma

ACKNOWLEDGEMENT
Karmanyevaadhikaaraste ma phaleshu kadaachana
Ma karma-phala-hetur bhur ma te sangostva akarmani

“We havea right to perform our prescribed duty,

but we are’t entitled to the furits of action. We
should never consider ourselves the cause of the
It is the most appropriate that I begin by expressing
my gratitude to the almighty for having blessed me
to purpose postgraduate study in General Surgery. I
dedecate this study to the God.
I also dedicate this dissertation to my father for his
unconditional love, extra care and for providing the
strength and time for my studies. I thank my family
and my friends for their unconditional support in all
my deeds.
It gives me immense pleasure to express my deep
gratitude, respect and sincere thanks to my
esteemed guide Dr.Rajendra Mandia sir . His insight,
high calibre and personal qualities have been
profoundly inspirational to me, not only for this study
but for the whole of my post graduation and shall
continue to be so in the future. I thank him for his
expertise in guidance and preparation of this
dissertation. I also thank him for sharing his
knowledge, especially during our PG teaching
program. The way he used to lead us in each clinical
discussion can never be forgotten. Thanks sir for
everything.
It is with great respect, I acknowledge Dr. R.K. jenew
M.S., professor and head of Department of General
Surgery, S.M.S. Medical College, jaipur for his
continuous support and his constant effort in the
upliftment for our academics.
 I also wish to deeply thank and acknowledge the
effort of my teachers Dr.Raj Govind Sharma,
Dr.Laxman aggarwal, Dr. Rajveer Arya, Dr.Sumita A. Jain,
Dr.Prabha Om, Dr.Richa Jain, Dr.Shalu Gupta Madam
,Dr.Jeevan Kakariya, Dr.Laxminarayan, Dr. Suresh Singh,
Dr.Bhupen Songra,Dr.Rajendra Bagari, Dr.Kavita garg
Madam ,Dr.Rajendra Bugaliya,Dr.Amit Goyal,Dr.Pardeep
Verma, Dr. Amit jain, Dr. Hanuman Khoja, Dr. Bhawarlal
Yadav,Dr.Dinesh Bharti,Dr.R.G.Khandelwal,Dr.Bajrang
Tak.
I would like to thanks Dr.Yogendra Dadhich and
Dr.Dinesh Sharma,for supporting me in all the victories
we gained in unit with full support in all ways.
I would also wish to thank my seniors, Dr.Piyush
Varshney,Dr.Sudarshan Gothwal,Dr.Sivank
Mathur,Dr.Harsh Deora,Dr.Navneet
Sharma,Dr.Ramswaroop, Dr.Surendra Pal
Morya,Dr.Mahendra Rathi,Dr.Punit Malik,Dr.Manoj
Jangid,Dr.Rohit Maheswari,Dr.Kulbhooshan
Haldinia,Dr.Harsh Jangid, Dr.Mahendra Khichad.
I would like to thank my friends,Dr. Dharmpal
Godhra,Dr.Pawan Meena,Dr.Pardeep
Tanwar,Dr.Gajendra Anuragi,Dr.Bhairu
Gujar,Dr.Krashan Kumar Yadav,Dr.Rajeev Sharma.
I would like to thank my juniors Dr.Jaspreet,Dr.Vikash
Joshi,Dr.Mukesh Kulhari,Dr.Naveen
Verma,Dr.Devendra Saini,Dr.Rahul Gupta,Dr.Gourab
Goyal,Dr.Asish Vyas and Dr.Dinesh Rahar.
Finally I thank Jaipur for all the memories.
Date:
Place:

Dr.Badri Narayan Sharma

INTRODUCTION
Hernia is derived from the latin word for
rupture. A hernia is defined as an abnormal
protrusion of an organ or tissue through a
defect in its surrounding walls. Irrespective of
country, race or socioeconomic status hernia
constitutes a major health-care drain.
The cause of an inguinal hernia is far from
completely understood but it is undoubtedly
multifactorial. It is estimated that 25% of men
and 2% of women develop inguinal hernia
during their lifetime.Patent processus
vaginalis,increase intra-abdominal pressure
and relative weakness of the posterior inguinal
wall are some of the factors associated with
inguinal hernia occurrence.Inguinal hernia
repair is one of the most frequently performed
operations worldwide.
There are three important landmarks in the
history of repair of inguinal hernia.
• 1. Tissue repair Eduardo Bassini 1888.
• 2. Onlay mesh Irving
Lichtenstein1984(tension-free) repair.
• 3. Laparoscopic Ger, Shultz, hernia
repair Corbitt,etc. 1999.
Inguinal herniorraphy through an anterior open
approach is a time tested,safe and well
understood operation with high success rate
and can be performed using general,regional or
local anaesthesia.The classical open surgery of
strengthening of the posterior wall of the
inguinal canal has evolved over a period of time
through various named operations like
bassini,macvay,shouldice to name a few,to the
present day gold standard of tension free
hernioplasty using prosthetic
mesh(lichtenstein)technique.
In 1984, Lichtenstein et al coined the term
“Tension-Free repair came into vogue and
was routinely advocated and aggressively
repair with open inguinal hernia repair were
eligible for inclusion. Inguinal hernia repair
using tension free mesh technique gives a
better result than a conventional sutured
repair.Overall recurrence rate is decreased
along with shorter hospital stay,faster return to
normal activities and a lower incidence of
persisting pain.
Even though hernia repairs were reported as
early as 1982 by Ger,the widespread interest in
laparoscopic hernioplasty did not occur till the
1990`s.Disappointing early recurrence
rates(even up to 25%), general
anaesthesia,longer operative times,cost of the
procedure and the steep learning curve were
the major stumbling blocks which prevented
the routine use of laparoscopy in the
management of inguinal hernias.This has been
possible because of advancement of modern
instruments and increasing pressure from the
industry as well as from patients who
increasingly demand less invasive
procedures,in the face of criticism from
conventional surgeons .
The preperitoneal placement of mesh that was
popularized by Nyhus and colleagues has been
considered as more physiological,safe and
secure technique of groin hernia repair.The
laparoscopic hernioplasty has several
advantages over its open counterparts as
evidenced by several studies.First and
foremost aspect from the patient point of view
is the reduced post operative pain and short
recovery period.Second,the entire
myopectineal orifice can be inspected,allowing
repair of any unexpected hernias thereby
reducing the chance of
recurrence.Third,laparoscopic hernioplasty
avoids the previous operative scar site in
patient with recurrent hernias.
Early uncontrolled studies claimed that
laparoscopic repair was superior to the
conventional open repairs regarding
postoperative pain, resumption of normal
activities, and return to work. Transabdominal
preperitoneal hernioplasty (TAPP), the
revolutionary concept in laparoscopic hernia
surgery was introduced by Arregui and Dion in
the year 1990’s.
Mckernan from USA and Dulucq from France
introduced a new concept of TEP repair which
avoided entry into the abdominal cavity.
Now TEP is considered as the standard
laproscopic Hernia repair.
The issue of indications for laparoscopic
inguinal hernioplasty remains unsettled and
awaits the results of several large randomized
trials.Prospective Randomized controlled
studies between laparoscopic inguinal
hernioplasty and tension free open mesh
hernioplasty has been coming out with results
since the procedure began.
In India,there is need to conduct more studies
to examine the results of laparoscopic hernia
surgery in comparison to the most popular
open Lichtenstein hernioplasty,to establish
standard guidelines and compare the results
with western literature.The present study is
being undertaken to evaluate these aspects in
our setting.
AIMS AND OBJECTIVES
The aim of this study is to assess and compare
litchtenstein’s open tension-free and
laparoscopic totally extraperitoneal mesh repair
in relation to:
- Operative time.
- Intra-operative complications.
- Post operative pain and neuralgia.
- Duration of nothing by mouth.
- Post operative hospital stay.
- Time required for return to work .
- Hernia recurrence.
MATERIALS AND METHODS
STUDY AREA:- Upgraded Department of General
Surgery, SMS hospital, Jaipur.
STUDY DESIGN:- Hospital based comparative type of
observational study.
STUDY PERIOD :- From January 2014 to January
2016.
SAMPLE SIZE:- Sample size is 42 subjects for each of
two groups at alpha error 0.05 and power 80%
assuming difference of means to be detected5+/-8
of return to work (as per seed article).So for the
study purpose 50 subject will be taken for each of
two groups. i.e. laparoscopic totally extraperitoneal
and litchtenstein open tension-free mesh repair
including drop out cases.
SAMPLING TECHNIQUE:- Every eligible case of
inguinal hernia will be allocated to each group by
alternate allocation ie.systemic random sampling
technique.
STUDY POPULATION:- All the cases of elective
inguinal hernia coming to SMS OPD in a single
surgical unit operated by a single surgeon in the
given period which meet the inclusion and exclusion
criteria.
INCLUSION CRITERIA:- All the cases with a diagnosis
of inguinal hernia willing to participate follow-up for
3 month and give written informed consent, coming
to SMS OPD in our surgical unit operated by a single
surgeon.
EXCLUSION CRITERIA :-
Patients not willing to participate in follow-up.
Pregnancy.
Patient on anticoagulants and other bleeding
disorder.
Any emergency surgery will be excluded from
the study e.g. peritonitis,strangulated,incarcerated
and obstructed inguinal hernias.
Patients unsuitable for general anaesthesia.
Patients with large,complete,indirect inguinal
hernia which were only partially reducible or
irreducible(SGRH classification grade V groin
hernia).
Prior groin irradiation or other inflammatory
process.
OUTCOME VARIABLE
The following measures are to be assessed for
both laparoscopic and litchtenstein open tension-
free procedures.
- Proportion of cases with injury to vital structure.
- Proportion of cases with post operative urinary
retention. -P
roportion of cases with post operative pain.
- Proportion of cases with incision site infection.
- Proportion of cases with post operative seroma
and hematoma formation.
- Proportion of cases with hydrocele formation.
- Proportion of cases with post operative
paresthesia.
- Mean duration of hospital stay.
- Avarage time for return to work.
- Proportion of cases with recurrence (follow up for
3month).

EMBRYOLOGY
INGUINAL REGION[82,109]
The testis originally lies on the posterior wall
of the abdomen at the level of the upper lumbar
vertebrae on the medial side of the
mesonephrons attached by a peritoneal fold
called mesorchism. Descent or migration of the
testis into its corresponding scrotal chamber is
accomplished by following the lead of the fibro
muscular band- gubernaculums testis. It arises
mainly within a peritoneal fold called the plica
inguinalis, which stretches from the inguinal
region to the lower end of mesonephrons, the
gubernaculums attains the greatest
development about the sixth month and is
attached above to the lower end of the testis
and below, it pierces through the abdominal
wall in its passage to the bottom of the scrotal
pouch, thereby forming the inguinal canal. The
processusvaginalis descends into the scrotum
dragging with it thin fascial prolongations of the
layers of the abdominal wall, thus the
processus vaginalis receives covering from the
aponeurosis of the external oblique and internal
oblique and from fascia tranversalis. The blind
extremity of the processus vaginalis gets
invaginated for the reception of descending
testis. As the migration of the testis proceeds,
the gubernaculums shortens and eventually
atrophies, but some trace of gubernaculums
persists at the bottom of the scrotum, below
tunica vaginalis forms the scrotal ligament
fixing the testis to the bottom of scrotal pouch.
By the end of the eight month the cavity of the
upper part of the processus vaginalis
disappears. The lower part of the processus
vaginalis is entirely cut off from the general
peritoneal cavity and consists of two layers, the
parietal portion of the tunica vaginalis lining the
scrotum, while visceral portion of that
membrane is applied on to the surface of the
testis. In female, the gubernaculums extends
from the lower poles of the ovaries to the
labium majus through the inguinal canal. This
part atrophies and is represented by the
ligament of the ovary while the lower part which
is developed is within the plica inguinalis is
represented by the round ligament of the
uterus, extending from the side of uterus to the
labium majus. A pouch of peritoneum is called
the canal of nuck, similar to the processus
vaginalis in the male, accompanies the
gubernaculums along the inguinal canal into the
labium majus. This is normally obliterated well
before birth, the occasional persistence of the
vaginal process after birth serves the genesis of
induction of inguinal hernia in the female.

ANATOMY[71,94,110]
The groin is the portion of the anterior
abdominal wall below the level of anterior
superior iliac spines. The pelvic bones form an
anchor for the muscles and aponeurosis of the
groin.The pubis and superior pubic (cooper’s)
ligament are medial. The epigastric vessels and
transversalis fascia condensation at the internal
ring are lateral. The anterior femoral sheath,
iliopubic tract and inguinal ligament are inferior
and the transverse abdominis aponeurosis and
its arch are superior.
Skin: Langer’s lines are transverse in the
groin with convexity facing downwards. The
anterior superior iliac spine of the ilium is easily
palpable in the lateral groin and the pubic
tubercle on the lateral margin of body
pubis.The deep ring is located approximately 2
cm above the skin crease between the thigh
and abdomen and midway between anterior
superior iliac spine and pubic tubercle. The skin
of groin is innervated by the
ilioinguinal,iliohypogastric and genital branch of
genitofemoral nerves.
 Subcutaneous tissues of the groin: This
contains the bulk of fat in the lower abdominal
wall.It is divided into superficial fatty layer
called Camper’s fascia and deeper
membranous layer called Scarpa’s fascia,
which continues as Colle’s fascia.The
superficial epigastric vein is frequently in the
midportion of the groin, more or less vertical
course upward in the subcutaneous tissue. It is
accompanied by superficial epigastric artery,
branches of superficial circumflex iliac vessels
laterally and external pudendal inferior to pubic
tubercle.
Scarpa’s fascia: Dense homogenous
membranous sheet of areolar tissue that forms
a definite lamina in the depth of the
subcutaneous tissue and is more prominent in
the region of the groin. Medial it is attached to
linea alba in the midline, descends onto the
dorsum of the penis forming the suspensory
and fusiform ligament. It also forms the
superficial fascia of the penis and continues
over the scrotum as the dartos tunic. It is
attached laterally to the crest of ilium.
Innominate fascia:It is well defined layer that
covers the external oblique aponeurosis and
inguinal ligament. Each of the abdominal wall
muscles has identifiable fascial envelopes. It
binds down the free lower edge of the inguinal
ligament to thigh and continues as fascia lata.
Intercrural fibers: Are present only in the
lower portion of innominate fascia. In the region
above and lateral to the superficial ring these
aponeurotic fibers take their origin from the
lateral half of the inguinal ligament and sweep
medially across the triangular gap in the
aponeurosis toward the midline. They serve to
limit or close the apex of the triangular opening
in the external oblique aponeurosis and bind
together. The aponeurotic margin of superficial
ring,thus resist the spreading of this aperture in
instances of inguinal hernia.

Musculoaponeurotic structures:-
External oblique muscle and aponeurosis: The
most superficial of the three flat
musculoaponeurotic layers that make up the
anterolateral wall of the abdomen. Its fibers are
directed downward, forward and medial from
the anterior superior iliac spine to the pubic
spine, the aponeurosis forms a free border
which is called inguinal ligament. The muscle
becomes totally aponeurotic in the groin with its
fibers running obliquely downward. It becomes
the external layer of the anterior rectus sheath
and further inserts on the pubis. The superficial
inguinal ring is a triangular opening in the
external oblique aponeurosis 1 to 1.5 cm medial
to the pubic tubercle. This opening is formed by
splitting of the external oblique.
Internal oblique muscle and aponeurosis: The
internal oblique muscle lies between the
external oblique and the transverse abdominis
muscle.The intermediate fibers form an
aponeurosis,which divides above the
semicircular line (of Douglas) into 2 lamellae at
the lateral border of the rectus muscle. The
anterior lamellae accompanies the external
oblique aponeurosis to form the anterior rectus
sheath. Below the semicircular line the
combined aponeurosis of all 3 lateral
abdominal muscles fuse and pass in front of
the rectus muscle as the rectus sheath.Fibers
are directed upwards, forwards and medially.
By its fleshy fibers it is inserted into the lower 3
or 4 ribs and their cartilages and by a broad
aponeurosis it is inserted into 7th, 8th and 9th
costal cartilages, Xiphoid process, linea alba,
pubic crest and pectineal line of pubis. Those
fibers, which originate from the inguinal arch
above the spermatic cord in the male and the
round ligament in females and becomes
tendinous. They insert conjointly with those of
the transverse abdominis into the crest of
pubis.It is this fusion of the tendinous portions
of the internal oblique and transversus muscles
that result in the structure known as the
conjoined tendon (inguinal aponeurotic flax).
Transversus abdominis muscle and aponeurosis:
This is the most internal of the three flat
muscles of abdominal wall. It passes medially in
a transverse manner around the lateral aspect
of the abdomen on to the anterior abdominal
wall.This is the key layer because of its role in
hernia repair. The general layer of the muscle
(lateral portion) and the aponeurosis (medial
portion) is towards the linea alba where it forms
the anterior rectus sheath below the
semicircular line of Douglas. In the groin it can
be divided into continuous and discontinuous
portions. The continuous portion is the
extension of the main muscle and aponeurosis,
the lower border of which arches above and
medial to the cord structures and is called
transversus abdominus arch which in 10%
cases is due to its dense nature and insertion
into pubic tubercle and crest is called falx
inguinalis. In 3% of case the falx receives
contribution from the internal oblique
aponeurosis also, thereby forming the
conjoined tendon. The discontinuous portion
lies below the transverses arch; it forms the
posterior wall of the inguinal canal, medial to
the internal ring. One fourth of these fibers
show marked variations and most often is
deficient, represented only by transversalis
fascia, thereby forming a critical weak spot in
the posterior wall of inguinal canal. The inferior
most edge of this layer is formed by “iliopubic
tract” a collection of aponeurotic fibers.This
tract arises laterally from the inner lip of the iliac
crest, the anterior superior iliac spine and
iliopectineal arch. The fibers traverse medially
separating away from inguinal ligament and
presents beneath deep inguinal ring. The
ligament forms at least one border of the
defect of indirect, direct or femoral hernia and
hence suited for repair.
Transversalis fascia: This is a portion of the
endoluminal fascia that encloses the abdominal
cavity and peritoneum. The portion which
invests the transverses muscle and
aponeurosis, is called transversalis fascia. It is
continuous with the lumbar,psoas, obturator
and rectus fascia. It is quite adherent to the
transverses muscleaponeurosis due to the
numerous slips of fibrous tissue that transverse
the muscle and attach to deep interparietal
fascia. Hence practically it forms part of the
transverses muscle aponeurosis fascia
complex. At the deep inguinal ring, there is a
tubular projection of this fascia internal
spermatic fascia that extend outward in blunt
funnel like fashion to cover the ductus and the
spermatic levels. The redundant transversalis
fasciaon the medial side of the deep ring is
called “transversalis fascia sling”.
Rectus sheath: The posterior rectus sheath is
lacking in any tendinous structure from the
semicircular line to the pubis. Above this point,
which is, located midway between the
umbilicus and the pubis, aponeurotic fibrous
sheath from the transversus and internal
oblique muscle reinforce the posterior rectus
sheath.In the groin aponeurosis of all the three
flat muscle contribute to the anterior rectus
sheath.
Peritoneum: Thin elastic membrane that serves
only to provide lubricating surfaces for its
contained viscera. Because of elastic character
of the peritoneum it does not act in prevention
of hernia.
Conjoint tendon (Flax inguinalis): It is formed by
the fusion of the aponeurosis of the inguinal
fibers of the internal oblique and transversus
abdominis muscles. The tendon is inserted into
pubic crest and medial part of pectin pubis. The
transversus muscle contributes 80% of the
conjoint tendon. The conjoint tendon has a very
variable structure and in 20% of the subjects it
does not exist as a discrete anatomic structure.
It forms the medial half of the posterior wall of
the inguinal canal.
Lacunar ligament ( Gimbernat’s Ligament): It is a
triangular fascial extension of the inguinal
ligament before its insertion to the pubic
tubercle. It is inserted at the pectin pubis and its
lateral end meets the proximal end of ligament
of cooper. It serves to broaden the attachment
area for the inguinal ligament by fanning.
Cooper’s ligament (Iliopectineal ligament): It
represents a shiny fibrous structure that
strongly reinforced periosteum of the superior
ramus of the pubis. It is a blend of fibrous
periosteum, recurved fibers of iliopubic tract
and inguinal ligament. It is anchoring structure
for laparoscopic hernioplasty.Cooper’s
ligament is particularly important in the surgical
correction of femoral hernias because it forms
a solid anchor along the inferior or posterior
aspect of these hernial defects through which
sutures may be placed with confidence that will
hold.
Inguinal ligament (Ligament of Poupart): It is the
lower, thickened portion of external oblique
aponeurosis. It extends from the anterior
superior iliac spine to pubic tubercle; this
extension is called as Poupart’s ligament. In
the lateral third, the inguinal ligament is directed
obliquely upward and outward. The inguinal
ligament is thick in this region and the fibers
attach to the anterior superior iliac spine and to
the iliopectineal arch. The middle third is less
thick, broader and has free lower border, it is
rolled so that the plane of inguinal ligament in a
parasaggital section near the pubic tubercle is
horizontal. The fibers are firmly attached to the
superior pubic ramus of the pubis along the
pectineal line and pubic tubercle. The effect of
rotation of inguinal ligament from an oblique to
a horizontal plane is to present a rounded
surface toward the thigh and hollow surface
toward the inguinal canal which acts as a
supporting shelf (Theshelfing border) for
spermatic cord. The gentle inferior curve
toward the thigh is brought about by the
attachment of its superficial investing fascia,
the innominate fascia, to the fascia of thigh.
The cremaster muscle: The cremaster muscle
consists of number of loosely arranged muscle
fasicule lying along the spermatic cord. They
are united by areolar tissue to form the sac like
cremasteric fascia around the cord and testis
within the external spermatic fascia. The
cremaster pulls up testis towards the superficial
inguinal ring and thus plays essential role in
testicular thermoregulation.
Inguinal canal: It begins at the site of emergence
of the spermatic cord through the transverses
aponeurosis (internal ring), and ends at the
pubic tubercle. It is oblique and 3.75 cm long
slanting downwards and medially parallel with
and a little above the inguinal ligament. It
extends from the deep to the superficial ring.
The boundaries are: anteriorly throughout by
the skin, superficial fascia, external oblique
aponeurosis, in its lateral one third also by
muscular fibers of the internal oblique.
Posterior, the transversalis fascia reinforced
medially by falx inguinalis (when present);
above, arched fibers of internal oblique and
transversus aponeurosis; below the inguinal
ligament and its continuation,lacunar ligament.
Hasselbach’s triangle: it is bounded medially
by the lateral border of then rectus sheath,
laterally by inferior epigastric vessels and below
by inguinal ligament.
Structures passing through inguinal canal
Spermatic cord: Originates at the deep ring and
consists of
a. Arteries: Testicular artery, cremasteric and
artery to vas deferens.
b. Veins: Corresponding veins mainly testicular
(Pampiniform plexus).
c. Nerves:Genital branch of genitor femoral
nerve, cremasteric nerve, and Sympathetic
plexus derived from Para aortic and pelvic
plexus.
d. Lymphatics of the testis.
e. Vas deferens and areolar connective tissue.
Coverings of spermatic cord from within are
processus vaginalis, internal spermatic fascia
(Transversalis fascia), Cremasteric fascia
(Internal oblique muscle and fascia), and
External spermatic fascia (External oblique
muscle and fascia).
Blood vessels: The external iliac artery gives off
two major branches before crossing beneath
Poupart’s ligament, where it becomes the
femoral artery. These tributaries, the deep
circumflex iliac and the inferior epigastric
vessels are not vital. The later serves as the
medial border of the deep ring, or the lateral
border of the direct triangle. The inferior
epigastric artery gives off two branches near its
origin, the external spermatic cremasteric
artery and the pubic branch. The main inferior
epigastric artery runs vertically upward in the
preperitoneal space to enter and ramify within
the rectus abdominis muscle, forming collateral
connections. The cremaster vessel exits along
the medial aspect of the deep inguinal ring and
originally must be sacrificed artery. The pubic
branch is originally quite small and lies on the
iliopubic tract, proceeding medially and then
downward to join the obturator artery arising
from the hypogastric artery. The testicular
artery arises directly from the aorta to supply
the testis. Clear visualization of the veins
following the course of artery is essential to
avoid trouble some bleeding during the repair
of direct or femoral hernia.
Nerves: The motor and sensory innervations of
the skin and musculoaponeurotic layers of the
groin are primarily supplied by ilioinguinal nerve
and iliohypogastric nerves. These nerves are
derived from the 1st lumbar nerve but may also
receive branches from 12th thoracic nerve. The
spermaticcord and testis are supplied by the
spermatic plexus, which contains sympathetic
and sensory fibers that enter the spinal cord
through the posterior roots of 10th, 11th, and
12th thoracic and 1st lumbar nerves. The pubic
bone and periosteum are innervated by the 2nd
and 3rd lumbar nerves. The genitor femoral
nerve, arising from the 1st and 2nd lumbar
nerves, supplies the cremaster muscle, the skin
of scrotum and adjacent thigh.
FIGURE 3:PARASAGITAL DIAGRAM OF RIGHT
MIDINGUINAL REGION

FIGURE 4: SHOWING DISSECTION OF INGUINAL

 REGION

Preperitoneal space[110]
Preperitoneal space (extra peritoneal or
preperitoneal) the easily cleavable space lies in
the abdominal cavity between the peritoneum
internally and the transversalis fascia
externally.The classical definition of the
preperitoneal space is correct, but if one
accepts the bilaminar formation of the
transversalis fascia into anterior and posterior
then two spaces are formed, one between the
peritoneum and the posterior lamina of the
transversalis fascia and one between the two
lamina of the transversalis fascia. In some
cases the posterior lamina is not well
developed and the space is limited by
peritoneum internally and anterior lamina
externally. Both lamina invert inferiorly on the
ligament of cooper. Superiorly they are perhaps
united somewhere at the anterior abdominal
wall and then continue upward as the
transversalis fascia. Significant parts of the
preperitoneal space includes, the spaces
associated with the structural elements related
to the myopectineal orifices of Fruchard, the
prevesical space of Retzius, the space of
Bogros and the retroperitoneal periurinary
space.
Ilipubic tract (Bundellete of Thompson ) runs
parallel and deeper to the inguinal ligament. It is
formed by the condensation of transversails
fascia from the medial aspect if iliac crest,
anterior superior iliac to the superior of public.
Myopectineal Orifices of Fruchaud-The orifice
beneath the arching lower border of the
transverses abdominis and internal oblique
muscles is bounded laterally by iliopsoas
muscle and medially by lateral edge of the
rectus abdominis and inferiorly by the pubic
pectin(bony margin of pelvis). The iliopubic
tract and the inguinal ligament divide it, which
separate the inguinal outlet above from the
femoral outlet below. All hernias originates
through this single weak area(myopectineal
orifices) in the groin.
Space of Retzius-The space of retzius extends
from the muscular floor of the pelvis to the level
of the umbilicus. Anteriorly, the bodies of pubic
bones, medial portion of the pubic rami and
posterior lamina of the rectus sheath bound it
at least to the level of arcuate lines of
Douglas.In the pelvis, the prevesical fascia and
the lateral pillars of the urinary bladder and the
covering of pelvic peritoneum bound the space
posteriorly. More superiorly the vesico-
umbilical fascia and peritoneum provide a
posterior wall for the space. The vas deferens
and the round ligament of the uterus traverse
the vesicoumbilical fascia enroute to the deep
inguinal ring. The space of retzius is closed
laterally along the line of fusion provided by the
inferior epigastric vessels and the tissue
encloses them.
Space of Bogros-In 1823, Bogros described a
triangular space between the abdominal wall
and the peritoneum that could be entered by
means of an incision through the roof and floor
of inguinal canal. Nyhus entered this space in
similar, but unidentical manner, for hernia
repair.
This space extends upward into the
retroperitoneal area and some workers state
that it is continuous medially with the space of
Retzius, but the author believe that
communication between two spaces is an
artifact of dissection or as a result of disease
process, they are normally separated from one
another by the plane of fusion along the path of
inferior epigastric vessels. The presence of
these easily cleavable spaces allows
preperitoneal placement of prosthesis with
minimal fixation as pioneered by Stoppa et al. It
also makes laparoscopic hernioplasty possible
since there are no major structures, which pass
through it. However there are important nerves
and vessels in the wall, which have to be
protected during cleavage.
Triangle of Doom is bounded by the vas
deferens medially,gonadal vessels laterally and
reflected peritoneum inferiorly. Dissection in
this region is very dangerous due to the
presence of iliac vessels. Spaw described this
triangle in 1991.
Corona mortis (circle of death ) is an area of
anastomosis between the anastomotic branch
of inferior epigastric artery and Obturator artery
and their corresponding veins over the public
ramus and iliopubic tract. It may be an area of
troublesome bleed.
Triangle of pain is bounded superiorly by the
iliopubic tract and medially by the gonadal
vessels is a dangerous area where all the
branches of lumber plexus are present. No
tracker should be placed in this region. “Avoid
stapling, suturing in the area below iliopubic
tract and lateral to testicular vessels”.
Square of Doom (Trapezoid of disaster): the
triangle of pain and the triangle of Doom are
collectively known as the Square of Doom.
Extended square of Doom consists of all three
areas i.e. the triangle of pain,triangle of Doom
and corona mortis.Therefore a familiarity with
the anatomy is mandatory for successful
laparoscopic hernia surgery.
Different Approaches to Inguinal Hernia
An inguinal hernia can be approached in a number of
ways:

Anterior approach-Anterior repairs are the most

common operative approach for inguinal
hernias; these include various techniques,
namely-
 Ilipublic tract repair
 Bassini’s repair
 Shouldice repair
 Cooper’s ligament repair(McVay repair)
 Tensionless mesh repair (Lichtenstein,
Gillbert’s plug ‘n’ patch, proline hernia
 system)
 Open preperitoneal repair-The open
preperitoneal approach is useful for the
repair of recurrent inguinal hernias, sliding
hernias, strangulated hernias, and femoral
hernias[211ramu]. Various technique
employing this approach are-
 Kugel’s method
 GPRVS (stoppa’s repair )- Giant
prosthetic reinforcement of the visceral
sac.
APPROACH TO THE PREPERITONEAL SPACE
OPEN
1.Cheatle - Henry approach (Infraumbilical
midline incision without opening peritoneum)
2. Nyhus approach (Transverse incision above
the inguinal ligament down to transversalis
fascia without opening peritoneum)
3. Anterior inguinal (Oblique incision just above
the inguinal ligament down to the posterior
inguinal wall without opening peritoneum.
4. Transabdominal approach (Peritoneum
opened)
LAPAROSCOPIC APPROACH
1. Transabdominal preperitoneal (with formation
of preperitoneal flap)
2. Intraperitoneal on lay mesh (Mesh fixed on
the peritoneal surface)
3. Totally extra peritoneal (Balloon inflation of
preperitoneal space)
4.Other extra peritoneal approaches-
Mckernan[203ramu] from USA and
dulucq[204ramu] from FRANCE introduced a new
concept of totally extra peritoneal repair (TEP) which
avoided entry into the abdominal cavity and thereby
avoiding complications related to the bowel.
This approach is made possible by the fact that the
peritoneal in the suprapubic region can be easily
separated from the anterior abdominal wall. This
space can be enlarged to help in dissection of the
hernia sac and insertion of the mesh. Several
techniques have been used.

1.Philips technique (TEP with peritoneoscopy)

Pneumoperitoneum is created and laparoscopic is
introduced into the peritoneal cavity. Under vision
into two working ports are placed in the
preperitoneal space. A 10mm trocar is placed into
this space and blunt instruments are used to widen
the space. Instruments are seen through the thin
layer as the laparoscopic is in the peritoneal cavity.
The laparoscopic and cannula are withdrawn
gradually till the preperitoneal fat is open and then
they are guided into the newly developed
space[224ramu].

2.Mckernan technique
A 2cm infraumbilical incision is made, rectus sheath
is incised and rectus muscles are retracted. A tunnel
is developed between the rectus muscle and the
posterior rectus sheath. A 10mm Hasson’s further
space is created by blunt probing. The other two
working ports are placed in the midline lower to the
umbilical port[225ramu].

3.Dulucq’s technique
The veress needle is introduced in the midline just
above the symphysis pubis. It penetrates the
lineaalba and enters the auprapubic space of
Retzius. CO2 insufflation is started with the needle in
this position. A 10mm trocar is blindly inserted into
the already created space through the lineaalba at
the level of Arcuate line[204ramu].

4.Subfascial approach
In this lineaalba is incised below the umbilicus and a
tunnel is made between the lineaalba and
peritoneum with blunt dissection. It is not
recommended due to increased incidence of
peritoneal laceration.
Our approach is the posterior rectus sheath
approach, where the trocar enters the plane
between the rectus muscle and the posterior rectus
sheath just above the preperitoneal space.

CONTENTS OF PREPERITONEAL SPACE OF INGUINOFEMORAL REGION

I. VASCULAR
1. Arteries
• Eternal iliac artery and its branches
• Deep circumflex iliac artery
• Inferior epigastric artery
2. Veins
• External iliac vein
• Deep circumflex iliac vein
• Inferior epigastric vein
• The Bendavid circle
II. NERVES
• Ilioinguinal nerve
• Iliohypogastric nerve
• Genitofemoral N
• Femoral N
• Lateral cutaneous N of thigh
• L1, L2 & L3 ventral rami
• Spermatic plexus (sympathetic & sensory)
COMPONENTS OF INGUINAL HERNIA[53,101]
The sac: Different parts of the Hernial sac
A. Mouth: This is path between the sac interior
and the abdominal cavity
B. Neck: This is the narrowest section between
the mouth and body of sac
C. Body: It lies between the neck and the
fundus
D. Fundus: This is the blind end or the distal
most part of sac.
Contents of Hernia: These can be almost any
abdominal viscous, except the liver.
Coverings: All the coverings of the sac of hernia
are derived from various layers of the
abdominal wall through which the sac passes.
Coverings of an indirect inguinal hernia are (from inside out)
as follows:
• Extra peritoneal fatty tissue
• Internal spermatic fascia
• Cremasteric fascia
• External spermatic fascia
• Two layers of superficial fascia
• Skin

In case of direct inguinal hernia the coverings are as follows:

• Extra peritoneal fatty tissue
• Fascia transversalis
• Conjoint tendon
• External oblique aponeurosis
• Two layers of superficial fascia and skin

CLASSIFICATION OF INGUINAL HERNIAS

[37,53,81,95,96,101,115]
Anatomical classification[53,101]
In this type of classification, the location of
hernial sac in relation to certain anatomical
structures is noted and accordingly the hernias
are classified. In case of inguinal hernia the
landmark taken is inferior epigastric artery.
Hernia lying medial to this artery is called direct
hernia and that lying lateral to it is indirect
hernia.
Classification according to descent of the sac[101]
• Bubonocoele:The hernia is limited to the
inguinal canal, the process vaginalis being
obliterated at the superficial ring.
• Funicular: In this type, the process vaginalis is
closed only at its lower end, just above the
epididymis. When the sac is occupied the
contents of the sac can be separately felt from
the testis, which lies below the hernia.
• Complete: The process vaginalis is patent
throughout, the testis appears to lie within the
lower part of hernia.

Classification depending on the contents of hernia

• Omentocele or epiplocele- when sac contains
omentum.
• Ritcher’s Hernia- when the sac contains a
portion of circumference of intestine.
• Littre’s Hernia- the sac contains Meckel’s
diverticulum.
• Enterocele- when the sac contains coils of
intestines.
• Cystocele- when the sac contains the urinary
bladder.
• Other varieties
- Sliding or hernia en-glissade(Contents-
caecum, urinary bladder)
- Maydl’s Hernia or Hernia-en-w( Contents-
w-shaped loop of intestine)
- Hernia of vermiform appendix
- Hernia containing female reproductive organs
- Hernias containing some abnormal viscera
like stomach, spleen.
- Dual hernia (saddle or pantaloon). Hernia on
either side of epigastric vessels.
CLINICAL CLASSIFICATION[101]
This is based on clinical presentation of hernia.
Reducible Hernia: In this contents of the sac
completely get reduced into the peritoneal
cavity on their own or on manipulation. A
reducible hernia imparts an expansile impulse
on coughing.
Irreducible Hernia: When the content of the sac
cannot be completely emptied from the sac.
This can happen due to adhesions, narrowing
of the neck or fixity of the contents of the sac.
Obstructed Hernia (syn. Incarcerated hernia):
Irreducibility + Features of intestinal
obstruction. In this type of hernia there is no
arrest of blood flow to the sac and its contents.
Strangulated Hernia: Irreducibility + Features of
intestinal obstruction+arrest of blood supply to
its contents leading to gangrene.
Inflamed Hernia: Occurs when its contents such
as an appendix, a salphinx or a Meckel’s
diverticulum become inflamed. The features
are
• Overlying skin becomes red and
erythematous
• Swelling becomes painful, tender and swollen
• It is not tense and is not associated with
intestinal obstruction.
Numerous authorities including Casten,
Lichtenstein, Gilbert, Rubins and Rutkow,
Bendavid, Nyhus, and others developed
classification systems that bear their names.
Casten Classification (1967)
Based on functional anatomy and operative
treatment
Stage I ― Indirect inguinal hernia. The internal
ring is normal as in infants and children.
Treated by high ligation of the sac.
Stage II― Indirect hernias including the sliding
variety with distortion and enlargement of the
internal ring, repaired by excision of the sac
and approximation of the edges of the internal
ring.
Stage III― All direct hernias and femoral
hernias, corrected by circumferential excision
of the direct and a cooper ligament repair.

Halverson and McVay Classification:

Based on pathologic anatomy and repair
techniques:
1. Small direct inguinal hernia - Repair consists
of high ligation of peritoneal sac and
reconstruction of internal ring.
2. Medium indirect inguinal hernia – Repair
consists of high ligation of peritoneal sac and
reconstruction of internal ring.
3. Large indirect and direct inguinal hernia –
Repair consists of high ligation of peritoneal
and reconstruction of internal ring.
4. Femoral hernia – Repair is done by cooper
ligament herniorrhaphy.
In 1993, Bendavid proposed a new system of
classification based upon the anatomical area,
the size of the hernia defect, and the length of
the sac. He called this as TSD (Type, Stage and
Dimension) classification and used the four
anatomic regions of the groin- medial to lateral
and above or below the inguinal ligament to
create four individual types of groin hernia. The
inguinal ligament separated the anterior from
the posterior region, and the epigastric vessels
separated the medial from the lateral. The
dimension measures the diameter of the
abdominal wall defect at its widest in
centimeters.
Bendavid Classification, 1994 [96]
Type I Anterolateral (Indirect)
Type II Anteromedial (Direct)
Type III Posteromedial (Femoral)
Type IV Posterolateral (Prevascular)

Bendavid Stages reflect the descent of the hernia

sac into the scrotum.
Stage I Sac in the canal
Stage II Sac beyond external ring-not in the
srotum
Stage III Sac in the scrotum
Dimension Maximum diameter defect in cm
.There are series of sub classification for type II
hernias with letter “M, C, L,E” denoting
whether defect is located through the
medial,central, lateral or entire portion of the
posterior wall of inguinal canal. When a portion
of viscus contributes to a sliding hernia, the
letter “S” is noted. Letter “I” for
incarceration.“N” for necrosis.
Nyhus Classification, 1993[83]
In 1993, Nyhus published a new system for
the classification of inguinal hernias that he
believed would “aid” in surgical decision
making and matching the type of hernia with
specific operations.
Type I Indirect inguinal hernia; internal
abdominal ring normal; typically in infants,
children, small adults.
Type II Indirect inguinal hernia; internal ring
enlarged without impingement on the floor of
the inguinal canal; does not extend to the
scrotum.
Type IIIA Direct hernia; size is not taken into
account.
Type IIIB Indirect hernia that has enlarged
enough to encroach upon the posterior inguinal
wall; indirect sliding or scrotal hernias are
usually placed in this category because they
are commonly associated with extension to the
space; also includes pantaloon hernias.
Type IIIC Femoral hernia
Type IV Recurrent hernia, modifiers A-D are
some times added, which correspond to
indirect, direct, femoral and mixed respectively
Gilbert Classification[10]
The Gilbert system classifies primary and
recurrent inguinal hernias repaired through an
anterior approach. Three factors are
considered:
• presence (or absence) of a peritoneal sac
• size of the internal ring
• integrity of posterior wall of canal
Type I
 A Type I hernia has a snug internal ring (<2
cm) through which a peritoneal sac of any size
passes. The posterior wall is intact.
Type II
The most common type of indirect hernia, a
Type II features a peritoneal sac passing
through a moderately enlarged internal ring (2
cm to 4 cm). The opening can admit one finger,
but is smaller than two finger breadths or
more.The posterior wall is intact.
Type III
Often seen with large scrotal and sliding
hernias. Type III has a peritoneal sac with a
large internal ring (> 4 cm) that is two finger
breadths or larger. Aportion of the posterior
wall medial to the internal ring is beginning to
breakdown.
Type IV
A typical direct hernia characterized by a
large or full blowout of the posterior wall of the
canal. The internal ring is intact, and no
peritoneal sac is present.
Type V
This is the most common type of recurrent
hernia. Type V is a direct hernia protruding
through a punched-out defect in the canal's
posterior wall. The internal ring is intact, and no
peritoneal sac is present. The system was later
modified by Rutkow and Robbins to include
Type VI - Combined hernia (Pantaloon)
Type VII- Femoral hernia

SGRH classification for laparoscopic repair of

groin hernia:
This functional classification grades groin
hernias according to the predictive level of
difficulty of endoscopic surgery. For multiple or
pantaloon hernias grading is according to the
dominant hernia. Intra operatively, the factors
considered as predictors of grades of difficulty
include:- Reducibility, degree of descent of the
hernial sac, previous hernia repair.
Grade 1
 Small, direct reducible hernia.
-Swelling appears on coughing/straining and
disappears on lying down
-Finger breadth size defect in the functional
direct floor(Hesselbach triangle)
Endoscopically minimal dissection of the sac
from the fascia transversails is required.
Grade 2
 Small, indirect, incomplete, reducible
hernia.
-Hernia swelling limited to the inguinal canal.
Endoscopically, the sac can be reduced
completely and may not require transaction or
ligation.
 Moderate sized direct hernia.
-Swelling is present on standing and reduces in
the supine position
-Thumb sized defect in the direct floor
Endoscopically, the sac needs to be dissected
off from the fascia transversails.
 Reducible femoral hernia.
Grade 3
 Moderate sized indirect reducible hernia.
-Hernia swelling(sac) extends beyond the
superficial ring upto the neck of scrotum but
does not descend to the testis.
Endoscopically, this type of hernia will require
transaction of the sac and ligation of the
proximal part.
 Large, reducible direct hernia.
-Involvement of the entire direct floor.
-Big bulge on the clinical examination over the
triangle of Hesselbach.
Endoscopically, creation of the space in the
midline is difficult.There is anatomical
distortion;stretching and lateral displacement of
the inferior epigastric vessels.
 Recurrent groin hernia.
Endoscopically, dissection is difficult in the
region of the spermatic cord and the space
lateral to it.
Grade 4
 Large, reducible, indirect inguinoscrotal
hernia.
-Large sac extending upto testis.The testis
cannot be palpated separately from the hernia
in the erect position.
Endoscopically, the deep inguinal ring is
enlarged.There is difficulty in dissecting the sac
from cord structures. Medial displacement and
stretching of the inferior epigastric vessels may
occur.Inadvertant opening of the peritoneum
may lead to pneumo peritoneum and dissection
the sac becomes difficult.There is higher
incidence of postoperative seroma/hematoma
formationbecause of the traction on the
sac.The chances of damage to cord structures
are increased.
Grade 5
 Large, complete,indirect inguinal hernia,
which is only partially reducible or
Irreducible.
 Irreducible femoral hernia.
-The sliding component includes the bowel or
bladder.
Endoscopically the sac is bulky. There are
adhesions between the contents of the sac and
sac wall. the sac often needs to be opened and
contents reduced laparoscopically.Injury to the
contents(bowel,bladder and omentum) while
reducing them is likely.
PROCEDURE

Lichtenstein Open mesh repair :

Position-Patients were operated in the supine
position.
Anaesthesia-General anaesthesia or regional
anaesthesia or local anaesthesia was used.In
case of local anaesthesia,1% lignocaine was
injected into skin and subcutaneous
tissue,permitting immediate incision.8-10ml of
anaesthetic solution was injected beneath the
external oblique aponeurosis to block all the
three nerves in the inguinal canal.Additional 3-5
ml solution were on the tissue over the pubic
bone and the peritoneum at the internal
ring,including indirect sac.In spinal anaesthesia
lignocaine or bupivacaine injected at L2-L3 or
L3-L4 level.
Dissection- A 4-5cm skin incision which starts
from the pubic tubercle and extends laterally
within Langer’s line is made. External oblique
aponeurosis was divided along the line of fibers
and its lower leaf freed from spermatic cord
and upper leaf from underlying internal oblique
muscle.A plane was developed between cord
structures and conjoined tendon and external
oblique. The cord with its cremasteric covering
is separated from the floor of inguinal canal and
pubic bone17. Cremasteric sheath is incised
longitudinally and indirect hernial sac is freed
from the cord to a point beyond the neck of sac
and inverted into the abdomen. Sac was
identified,separated from cord structures,and
opened,and the contents reduced back in
peritoneal cavity. The sac was then transfixed
with vicryl and divided at the deep ring as high
as possible.In case of large indirect inguinal
hernia,sac was transacted at the mid-point of
the canal,with the distal section left in place
after incising the anterior wall of the sac to
prevent obliteration and subsequent hydrocele
formation.In case of direct hernia,sac was
invaginated by applying continuous sutures
between ilio-pubic tract and transversalis
fascia over which the synthetic mesh was
applied.The external oblique aponeurosis was
separated from internal oblique muscle at a
point high enough to accommodate the mesh.
Mesh Placement-A
polypropylene(prolene)mesh of 3”*6” size
was used and trimming was done as necessary
so that the patch overlaps the internal oblique
muscle aponeurosis by at least 2 cm above the
border of hesselbach triangle. The medial end
of the mesh is cut to the shape of the medial
corner of inguinal canal with the cord retracted
upwards, the rounded corner is sutured with
nonabsorble monofilamented suture material to
the anterior rectus sheath on the public bone
and overlapping the rectus sheath and
periosteum by 1 to 1.5 cm. This is a crucial step
in the repair, because failure to cover this bone
with the mesh can result in recurrence. A slit
was made at the cranial end of the
mesh,creating a wider tail medially and a arrow
one laterally,and the cord positioned between
the two tails of the mesh.the mesh was sutured
to the aponeurotic tissue over the pubic bone
overlapping the bone with 2-0 polypropylene
suture medially,with inguinal ligament
inferiorly and to the conjoined tendon above. If
there is a concurrent femoral hernia, the mesh
is also sutured to Cooper’s ligament 1 to 2 cm
below its suture line with the inguinal ligament
to close the femoral ring.
Laterally,the mesh was sutured to the inguinal
ligament to a point just lateral to internal ring
.Cranially the two tails of mesh were overlapped
leaving enough space for the cord to not get
strangulated and sutures applied.The two tails
of the mesh now form the new internal ring.The
excess mesh was trimmed leaving 3-4 cm
beyond the internal ring.Perfect hemostasis
was ensured.The external oblique aponeurosis
was sutured back as it was with 2-0
prolene,closing the inguinal canal.The skin was
approximated with 3-0 Ethilon or staples
applied.
Laparoscopic Total Extra Peritoneal (TEP)
repair:
Preoperative urinary catheterization-All
patients were routinely catheterized on the
morning of the surgery.
Position-Patients were operated in supine
position.
Anaesthesia-General anaesthesia was used in
all 42 patients.
Team setup-The surgeon stand on the right
side of the patient and camera assistant on the
other side.The monitor was placed at the foot
end of the table.The hernia contents were
reduced manually to help in operative
procedure later.
Port position-Three midline trocars were used
as described by ferzli et al.infraumblical 10mm
camera port and two midline 5 mm working
ports,one 2 cm above pubic symphysis and the
other in between the first two.
Dissection-After painting and drapping,a
subumblical 2 cm transverse incision was given
in the midline extending to the side of the
hernia.Blunt dissection was performed until the
anterior rectus sheath was reached.Two
Langebach right angle retractors facilitated this
dissection.A 2 cm transverse incision was
made on the anterior rectus sheath on the side
of the hernia.The rectus muscle was dissected
free from the linea alba and retracted laterally
with the retractor thus opening the space
posterior to the muscle.Blunt finger dissection
was done just posterior to the muscle and
anterior to the posterior rectus sheath and
peritoneum creating the pre peritoneal
space.Next a balloon(made of double fingers of
sterile latex gloves over the 5 mm suction
cannula tip)was inserted in the space thus
created.The balloon was inflated with 180-200
ml of sterile saline slowly and left in place for
five minutes for hemostasis.It was then
deflated and removed.A 10 mm cannula was
inserted in the space without trocar.It was
tightly fixed to the rectus sheath with sutures to
prevent movement in and out and CO2 leak
from the port site.The CO2 insufflation was
connected to the canulla and 10 mm 0 degree
telescope & camera introduced through the
port.Further blunt dissection in the loose areolar
tissue was done & space created upto the
pubic symphysis for the other midline
ports.Next,a 5 mm trocar was introduced in the
midline 2 cm above the pubic symphysis and
the third between the first two ports,under
direct vision taking care not to injure the
peritoneum or bladder.Through these ports two
5 mm dissectors were introduced.With the help
of dissectors the preperitoneal space was
dissected,starting from the pubic symphysis in
the midline & proceeding laterally upto the
psoas muscle.Dissection was taken across the
midline medially.Lateral limit of the dissection
was the anterio superior iliac spine.During
dissection pubic ,superior pubic ramus with
iliopubic tract,cord structures and inferior
epigastric vessels were used as important
landmarks.It was insured that inferior epigastric
vessels stay at the roof of the space created
and act as a guide to the cord structures.
The Direct hernia sac when present was the
first structure to be reduced starting from the
midline laterally,medial to the inferior epigastric
vessels. The fundus of the direct sac was
separated from the redundant fascia
transversalis which has appearance like a
reverse sac.At the completion of this
dissection,the cord structures were identified at
the deep ring.Lateral to inferior epigastric
vessels in the case of indirect hernia,the
peritoneal sac was separated completely.The
sac was then pulled back completely from the
deep ring.The sac was needed to be divided in
10 cases and the proximal sac was ligated with
a preformed catgut 1-0 endoloop.Direct sac
was left open and not dissected from the cord
structures to prevent any injury to the
cord.Peritoneal tear during dissection of
indirect sac occurred in initial few cases.There
was loss of space due to leak of CO2 into the
peritoneal cavity.A verres needle insertion into
peritoneal cavity at Left hypochondrium was
enough to release the pneumoperitoneum and
dissection to proceed further.The peritoneum
was pushed towards the floor of the space
completing the reduction of the sac.Vas
deferens was identified and
preserved.Complete haemostasis is
maintained.
Mesh placement-Next,a
polypropylene(Prolene) or composite(Vipro)
mesh 15*15 cm or 12*15 cm was rolled and
introduced from the subumblical port after
removing the camera.The camera was
reintroduced and mesh unrolled inside.The
mesh was unrolled in such a way that 1/3rd of
the length was over the roof and the rest
covered the myo-pectiineal orifice of Fruchard
and the floor.
The vertical limb of the mesh was held by one
dissector at the lateral margin and the other
dissector was used to unroll the mesh over the
peritoneum up to the semicircular line of
Douglas,thus covering the entire peritoneum
including the reduced hernia sac which now lay
posteriorly.This also ensured lateralization of
the cord with respect of the deep ring.Tackers
were applied above the ileopectineal line.One
tacker were applied to fix the mesh at cooper`s
ligament medially.Sometimes no need for
fixation of mesh.In some conditions such as
non affordability of tackers, mesh canbe fixed
by sutures.
The two dissectors were used to ensure that
mesh lay straight at the upper edge and the
pneumo desufflation was carried out under
vision to prevent the mesh from folding.The
peritoneum along with the mesh was seen to
rise against the anterior abdominal wall.The
ports were the removed.At the subumblical port
site,the anterior rectus sheath was closed with 1
-0 vicryl and skin suture applied.
Operative time was noted from the time of first
incision to the last skin suture applied.
Post Operative Monitoring-Patient were shifted
to the surgical wards from the anaesthesia
recovery room. Patients were adviced to do
day to day activities immediately after
recovering from the effect of anaesthesia.The
patient were encouraged to sit up,move about
in the evening and allowed to resume daily
activities and eat and drink normally by the
evening.All patients catheterised before
surgery is removed postoperatively as soon as
possible.Early postoperative complications like
urinary retention ,nausea,pain etc. are noted.IV
fluids were stopped when patients were able to
tolerate oral intake.VAS Pain score chart was
filled according to patient perception of the
postoperative pain. Patients are discharged
when they are willing and comfortable,are
ambulatory and taking orally.

COMPLICATIONS OF INGUINAL HERNIA SURGERY

[3,4,38,92]

Complications cannot be eliminated altogether

but may be minimized by maintaining their
awareness of their possibility and by using
meticulous and precise surgical techniques.
SURGICAL COMPLCIATIONS
Hemorrhage :Serious haemorrhage can occur
after trauma to
a. Pubic branch of obturator artery.
b. Deep circumflex iliac vessels
c. Inferior deep epigastric
Damage to first three is troublesome. The
vessels may be ligated with impunity. External
iliac vessels must not be ligated and
haemostasis achieved by applying pressure.
Transection of spermatic cord : In rare instances
in which unintentional transaction of the
spermatic cord occurs during an operation.
Fever, tenderness and swelling of the testis
follow in two third of the patients. But one third
of patients are asymptomatic. Testicular
atrophy or hydrocele may ensure in up to one
third (10) of patients but routine orchidectomy is
unnecessary.
Severance of nerve : The ilioinginal,
Iliohypogasrtic and both the genital and femoral
branches of the genitomoral nerve are
vulnerable to injury during groin hernia repair.
Ilioinguinal nerve provides sensory
innervation to base of penis and upper scrotum
and adnacent thigh. Iliohypogastric nerve
provides sensation to the supra public area.
The genitofemoral nerve provides motor
innervation to cremastric muscle and sensory
innervation to skin of the penis and scrotum.
Fortunately, there are multiple cross
connections between peripheral nerves in the
groin and considerable central segmental
overlap in their sensory
representation.Prolonged anesthesia of skin
does not follow injury to one of these nerves. In
genitofemoral branch injury patient may
complain of testis on the side operated rests in
somewhat more dependent position. It is
impractical to attempt anastomosis. The nerve
ends should be ligated to close the neuronal
sheath and enforce development of the
inevitable post-traumatic neuroma with in
nerve sheath. Nerve entrapment by a suture
result in prolonged post operative symptoms to
avoid this careful identification of nerves and
protect them during dissection.
Severance of testicular blood supply: Internal
spermatic or testicular artery arises from aorta
and is the main arterial supply to testis. External
spermatic artery a branch of inferior epigastric
artery which supplies cremastric muscle.
Potentially a rich collateral circulation exists at
the upper end of the testis between end
branches of the vesicle and prostatic arteries
and the internal spermatic and differential
arteries also have free anastomotic
connections to vessels of spermatic cord just
external to the superficial inguinal ring.
Every precaution should be taken to
prevent damage to vessels of cord. If damage
occurs, repair being impractical ligation is
necessary. Ligation of the major artery to the
testis at the level of the deep inguinal ring does
external collateral circulation is undisturbed.
Preservation of this collateral circulation is
accomplished by not dissecting the testis from
the scrotum during repair.
Trauma to vas deferens: Trauma to vas deferens
can be one of transaction or obstruction.
Transection is a mishap that usually occurs
through open repairs, particularly in recurrent
hernial repairs. Because there are two vas
diferens transaction of a single vas may be
considered minimal importance by the surgeon
but rarely by the patient. Unless permission for
transaction obtained preoperatively.
Reanastomosis should be attempted with
‘O’ prolene as stent and with interrupted 3/0
chromic catgut approximately 50% usually are
considered to function after repair32.
Obstruction can result from handling of vas
with forceps causing fibrosis and adherent to
posterior inguinal wall leading to outflow
obstruction and dysejaculation. In 0.04% of
herniorrhapies.
Damage to intestine : Complications relating to
bowel during open technique of hernia are
limited in two situations.
1. Freeing of incarcerated or strangulated
segment of bowel.
2. Inadvertent laceration of large bowel in
presence of sliding hernia.
During high ligation blind suturing is never
acceptable because of the possibility of
incorporating a loop of intestinal within the
suture leading to obstruction, abscess with in
the intestinal wall or fecal fistula. The bowel
may be injured either by entering it directly or
by devitalizing it through interrupting its blood
supply. Incised bowel should be immediately
repaired with interrupted seromuscular sutures
of fine silk. Devitalised bowel must be dealt with
either by exteriorization or resection. If
resection is necessary in unprepared bowel, the
anastomosis in the sigmoid should be
protected by a temporary diverting transverse
colostomy.
Injury to bladder:
For open: Medial side of direct inguinal hernia
often contains a sliding portion of bladder wall.
If injury to bladder wall occurs the defect
should be closed in two layers with interrupted
chromic catgut sutures and an indwelling
urethral catheter inserted for 5 days. Repair of
hernia should be completed after the bladder
injury has been treated.
For LAP: Injury to the bladder may occur from
surapubic trocar placement or from dissection
during the course of the operation. Bladder
injury may be obvious when blood and gas
collect the drainage bag if a foley catheter is in
place. When there is any doubt about bladder
to look for leakage. Bladder injury recognized
during laparoscopic should be repaired
laparoscopically if the experience of the
surgeon in sufficient, followed by bladder
drainage for 7 to 10 days. Bladder injury may be
manifested in delayed fashion as hematuria
and lower abdominal discomfort. A retrograde
cystogram generally confirms the diagnosis
larger defects necessitate repair.

Post operative complications[92]

1. General causes : Systemic complication occur
at a rate comparable with that after other
surgical procedures of the same magnitude.
Atelectasis and pneumonitis were most
frequent followed by thrombophlebitis and
urinary retention.
2. Scrotal Ecchymosis : It manifests during 2nd
of 3rd post operative day. The skin of the
scrotum has become discoloured by a dark
purple ecchymosis. This complication results
from dissection of blood from the inguinal canal
in to the scrotum following the path of
spermatic cord. Usually there is little or no
haematoma palpable in the scrotum or the
inguinal canal. The usual cause of scrotal
ecchymosis is a small vessel overlooked intra-
operatively. Ecchymosis resolves
spontaneously with in few weeks post
operatively.
3. Swollen Testis : Most common cause is that
the tissues of the deep ring are closed too
tightly. About the spermatic cord less frequently
interruption of venous and lymphatic vessels
has occurred in the course of the dissection of
an indirect inguinal hernial sac or the spermatic
cord as it passes through the deep inguinal ring
or thrombosis of pampinform plexus has
occurred.Collateral lymphatic and venous
channels usually develop in this situation and
the swelling eventually subsides support of
swollen testis and to restrict the activity to
reduce the degree of discomfort.
4.Ischemic orchitis and testicular atrophy :
Ischemic orchitis is a syndrome that can
occur after inguinal hernioplasty consists of
 painful, tender, and swollen testicles and
spermatic cord. Fever precedes testicular
manifestations. The testicular abnormality is
apparent only on 2nd or 3rd days after the
operation. The complication usually
develops as the result of Arterial
insufficiency or venous insufficiency or
combination of both. Testicular atrophy is
especially prone to occur after repair of an
indirect complete scrotal hernia.Ischemic
orchitis may resolve completely or progress
to testicular atrophy. Only rarely does the
testicle become gangreneous. The fever
disappears promptly but pain and
tenderness may lost for several weeks. It
takes 4-5 months for size and shape to
come to normal. In most cases atrophy is
apparent with in few months of surgery. But
in some patients takes 12 months before
the atrophy is established an atrophic testis
is non tender and painless.
Although atrophy of one testis does not
diminish a patients fertility or sexual potency
such reassurances are often not completely
satisfying to many patients. It can be minimized
by careful, non traumatic dissection of the
spermatic cord by attention 61 to preservation
of venous and lymphatic drainage and by
avoidance whenever possible of dissection of
the testis and the distal portion of the spermatic
cord from the scrotum.
5.Hydrocele : Collection of fluid in the scrotum or
along the spermatic cord may result from
leaving portion of distal hernial sac in situ.
Hydrocele like collections of fluid also may form
if lymphatic or venous drainage is unduly
interrupted in the course of hernial repair. Mild
swelling disappears with in few days after the
operation. Most of the large swelling due to
fluid collection respond to simple aspiration of
the fluid by syringe.
6.Wound infection : The incidence of wound
infection after primary repair of groin hernia is
approximately 1%,in recurrent hernia and
laparoscopic approach up to 3%[245ramu]. If
the infection extends below external oblique
aponeurosis, recurrence becomes very high.
Wound infection managed by early recognition,
reopening of wound to permit drainage, and
appropriate local care, systemic antibiotic
indicated if symptoms of invasive sepsis.
7.Recurrence[47,48]: A weakness in the operation
area necessitating further operation’. There is
no question that both through anatomical
knowledge and skilled technique necessary for
successful repair. One technical point deserves
particular emphasis “Absence of tension in the
completed hernial repair is essential to
success.
Patients with bilateral hernias have a much
greater chance of recurrence than patients with
unilateral hernia. Although recurrence of hernia
is related in a small minority of patients to
inadequacy of the patients fascial structures,
the reason which accounts for the vast majority
of hernial recurrences following operative
repair is a technical failure on the surgeon. The
most common mistake is the creation of too
much tension in the wound. A hernia repaired
under tension will not heal normally and is
subject to disruption throughout the period of
wound healing. It would be one thing if relief of
tension was a difficult matter to arrange in
repair of a groin hernia. But relief of tension is
easily achieved by appropriate use of a relaxing
incision. Whenever a hernia, other than the
smallest indirect inguinal hernia is repaired.
 Recurrence after 6 months are due to
factors other than technical error or selection of
inferior producer43. Recurrence is also due to
decreased collagen synthesis. Other causes of
recurrence are infection, too much tension
during repair. Prevention of recurrence is done
by supplementing the basic repair with
additional support by prosthetic mesh. The over
all recurrence reported is 10% for primary and
25% for recurrent inguinal hernia. The often
quoted rate of recurrence after a laparoscopic
repair is on the order of 3%. Similar recurrence
rates are also routinely seen after the open
tension free repair. Most of these data are
from specially centers however and the overall
recurrence rate after laparoscopic
herniorrhaphy may be closer to 10%[248ramu].
Hernia recurrence may be difficult to
distinguished clinically from lipoma of the cord,
a seroma or a bulge in the internal oblique
muscle and may require imaging with
ultrasound, CT or MRI. Definitive identification
of recurrence is especially important to avoid
unnecessary surgery in those with groin pain. It
is logical to approach through previously
undissected plane and thus many surgeons
prefer to perform an open anterior tension free
repair for a hernia previously repaired
laparosopically. Laparoscopic preperitoneal
herniorrhaphy after a previously failed
endoscopic herniorrhaphy is controversial. A
strong argument can be made that this
procedure should not perform except in cases
in which failure has occurred in both the
conventional and the preperitoneal space.
Nevertheless, surgeons are confronted with the
patients who request a laparoscopic repair
regardless. This situation most commonly
comes up when the patients has previously
undergone conventional repair on the opposite
side. In the hands of experienced laparoscopic,
this would appear to be an acceptable
approach. However, it is a technically
demanding procedure with the potential for
serious complications for the uninitiated, most
notably bladder injury. Therefore, referral to a
specially center by the practising surgeon
should be considered in such case. The TAPP
procedures is the safest laparoscopic
hernioplasty for these recurrence hernias in as
much as a significant series using the TEP
approach has not been reported.
In a retrospective review by felix et
al[249ramu] patients who had lap
herniorrhaphy at specialized centers were
analyzed for recurrence and possible etiology.
7661 patients with 10,053 hernias were repaired
by TAPP or TEP repair. The recurrence rates
was 0.4% (35) on a median follow up of 36
months.
The following were causes for failure :
Inadequate lateral fixation with small
mesh (8.57%)
Inadequate lateral fixation (31%)
Missed lipoma of the cord (11.4%)
Inadequate mesh fixation (22.3%)
Missed hernia (11.4%)
Hernia through a key hole in the mesh
(14.29%)
It was also noted on further analysis that as
surgeons gained experiences, the incidence of
recurrence decreased. The 33 recurrence in a
series of 5500 repairs were analyzed in two
phases after modification of technique. They
found that during phases 1 it was mostly the
size of mesh and insufficiency in the region of
its incision but in phase, if it was a problem of
mesh dislocation. Altogether the rate of
recurrence decreased from 2.8% during phase
1 to 0.36% in phase 2[250ramu].
Causes for recurrence in laparoscopic hernia
repair[250ramu]
Reason Phase 1 Phase 2
(n=17) (n=16)
Mesh to small 9(47.4%) 3(16.7%)
Insufficient 8(42.1%) 3(16.7%)
mesh slit
Missed lipoma 2(10.5%) 2(11.1%)
Migration of 0(0%) 7(38.8%)
mesh
Anatomy 0(0%) 3(16.7%)

8. Missed hernia : A missed hernia is a hernial

defect present at the time of primary hernial
repair but unrecognized by the operator and
appearing subsequently as a new hernia. From
the patient’s point of view this is recurrence.
Whether the hernia occurs through the repaired
portion of the inguinal region or not is a matter
of no consequence to the patient. Proper
exploration of the inguinal areas at the time of
operation should have uncovered the missed
hernia. Missed hernias can be avoided by
careful inspection and palpation of all potential
hernial areas in the groin when theprimary
hernial repair is being conducted.
9. Other complications :
1. Urinary retention: Older age, general
anesthesia, aggressive hydration, narcotics for
pain relief and history of prostatic symptoms
predispose to urinary retention after hernia
repair. Intermitted catheterization or temporary
placement of an indwelling urinary catheter is
usually adequate therapy. Prophylactic use of
prazosin after herniorrhaphy may significantly
reduce the incidence of urinary tetention and
catheterization.
2. Neuroma : Ilioinguinal and femoral neuritis
caused by entrapment by sutures or the actual
formation of symptomatic neuroma. Most
syndromes can be expected to resolve
spontaneously without treatment. Those with
persistent symptoms can be treated by nerve
block. After Ist post operative month rarely
wound re explored to localize neuroma and
excision.
3. Hematoma
4. Seroma: These are common and are almost
entirely due to the us of prosthetic materials.
Treatment is aspiration symptomatic benefit.
5. Sinus formation
6. Persistent post operative pain
7. Groin pain : Chronic Groin pain is a major
cause of morbidity after inguinal hernia surgery.
Its incidence may be as high as 53% at 1 year of
follow-up[244ramu]. Evaluation of post
herniorrhaphy groin pain involves ruling out a
myriad of causes, including muscle injury,
adductor strain,nerve
entrapment,neuroma,periostitis of public
tubercle, adductor tendinitis and lumbosacral
disorders. The superior soft tissue resolution
offered by MRI makes it the most useful
diagnosis modality for evaluation of post
herniorrhaphy groin pain. The etiology of this
pain can be
Nociceptive-as result of direct
tissue damage
Somatic
Visceral
 Neuropathic
Treatment of all three types of pain is
initially conservative and consists of
recurrence, anti-inflammatory medications,
cryotherapy and local nerve blocks, except
when sudden serve groin pain is present
immediately after surgery, which suggests a
sutured or stapled nerve, which requires
immediately exploration.
8.Numbness and paraesthesia, sexual
dysfunction
Complications speciallyassociated with
laparoscopic approach :
Major vascular injury: The risk major vascular
injury requiring operative repair is
0.08%[231ramu]. many authors believe that this
incidence is seriously underestimated because
such injuries commonly go unreported. Access
to the peritoneal cavity is the most crucial
phase of laparoscopic, and over three quarters
of major vascular injuries occur during insertion
of the veress needle or the trocars at the
beginning of the procedure. The vessels most
frequently involved include the aorta, inferior
vena cava and the iliac artery and vein.
Mesenteric and omental vessels, splenic
vessels and renal vessels have been injured
occasionally. Epigastric vessels running in the
result sheath may be injuried during the
placement of secondary trocars. The use of
diposable trocars with safety shields, optical
trocars, and blunt-tipped cannulas has not
eliminated this dramatic complication. It has
been described during the open approach with
the Hasson’s cannula for initial access.
Knowledge of the anatomic relationship
between the anterior abdominal will and the
retroperitonium, careful introduction of the
veress needle, and avoidance of the
trendelenberg position during initial access
have been reported to decrease the incidence
of this complication. Major vascular injury is
manifested as either hemoperitonium or
retroperitoneal hematoma. Mortality has been
estimated to be as high as 36% expenditious
laparotomy with repair of the vessels can be
controlled by applying pressure applied with a
cannula. Occasionally, suture ligation required
which is now possible with the use of an “exit
device” for transfascial suture placement.
 Gas Embolism: Gas embolism is a very rare, but
potentially life threatening complication. Carbon
dioxide can be introduced into a large
vein,most likely the result of inadvertent
cannulation by the veress needle and trapped
in the right ventricle, where it causes outflow
obstruction into the pulmonary artery and
sudden circulatory collapse. Careful insertion in
the veress needle and the usual confirmatory
tests of its intraperitoneal position should keep
the incidence of air embolism.
Intestinal obstruction: With the advent of the TEP
repair it was hoped that bowel related
complications would be minimized or
eliminated. However, frequently unrecognized
peritoneal defects are common after the TEP
repair, especially in patients with previous lower
abdominal surgery; adhesive small bowel
obstruction is theoretically possible because of
the intra-abdominal dissection. Fortunately this
complication is exceedingly rare.
Shoulder pain: Shoulder pain is commonly seen
after any laparoscopic procedure and can be
quite troublesome to the patient. It is commonly
assumed that residual carbon dioxide in the
peritoneal cavity is trapped under the
diaphragm and causes diaphragmatic irritation
and referred pain to the shoulder, but has never
been proved. Nevertheless, it is standard
practice to completely deflate the
pneumoperitoneum at the conclusion of the
laparoscopic inguinal herniotherpy with the
patient still in the trendelenburg position. A low-
pressure pneumoperitoneum has also been
recommended[237ramu].
Subcutaneous and preperitoneal emphysema :It is
usually harmless and resolves spontaneously,
aided by messaging the swollen anterior
abdominal wall towards the nearest trocar site.
Preperitoneal emphysema is due to a
malpositioned veress needle and can be
frustrating to the surgeon. It can be avoid by
using a Hasson’s cannula for primary access.
Diaphragmatic dysfunction: Diaphragmatic
dydfunction has been described after a variety
of laparoscopic procedures. Its exact etiology is
unclear, but the effects are transients and
generally resolve spontaneously by 24 hours.
Cardiac Arrhythmia: Bradycardia may
occasionally follow the creation of
pneumoperitonium. It is reflex vagal response
to peritoneal distention. It can usually be
managed by stopping the inflow of carbon
dioxide temporarily and administrating an
anticholinergic drug. Once the heart rate has
recoverd, pneumoperitonium can be recreated
gradually.
Deep vein thrombosis: The incidence of deep
thrombosis after laparoscopic procedures is
about 0.33%[239ramu]. thromboprophylaxis for
laparoscopic should be the same as for
conventional surgery, that is, tailored to
individual risk and continued for a minimum 7 to
10 days. Graduates compression devices,
maintenance of relatively low insufficient
pressure, keeping use the reverse
trendelenburg position to a minimum and
intermittent release of the pneumoperitoneum
in longer procedures are other measure that
can decrease the incidence deep venous
thrombosis.
Infertility: Injury to the vas deferens or the tests
can cause infertility. The incidence of injury to
the vas deferens during inguinal hernia repair is
0.3% In adults and up to 2% in
childerens[240ramu]. The vas deferens may be
injured during dissection and mobilization or
during fixation of the mesh. Traction injuries to
muscular wall of the vas deferens sustained
during mobilization may interface with transfer
of spermatozoa. Unilateral injury to the cord
lead to exposure spermatozoa to the immune
system and the formation of antisperm
antibodies, thus causing infertility[241ramu].
Ischemic orchitis : Interruption of blood flow to
the testis because of inguinal herniorrhaphy
may results in Ischemic orchitis and
subsequent testicular atrophy. It is manifested 1
to 3 days after surgery as a painful, enlarged,
firm testicle accompanied by low-grade fever.
Its incidence in large series of TEP repairs was
0.11%[242ramu]. Complete excision of all
indirect inguinal hernia sacs is through to be an
important cause secondary to trauma to the
testicular blood supply, especially the delicate
venous plexuses. Large indirect inguinal-scrotal
hernia sacs should be divided just distal to the
internal ring. The proximal portion of the sac is
ligated and the distal part is opened on its
anterior surface as far distally as convenient.
Contrary to popular opinion in the urologic
literature, this technique does not result in an
excessive rate of postoperative hydrocele
formation[243ramu]. Treatment is largely
supportive and consists of elevation and anti-
inflammatory medication.
REVIEW OF LITRATURE
HISTORICAL ASPECTS OF INGUINAL HERNIA
ANCIENT TIMES[48,76]
The word hernia derived from the Greek
“Hernios”,meaning “Nad”or
“Shoot”.Hernia is known to mankind since
time immemorial.Shushruta in vedic period
described hernia as”Antra-vriddi” and had
taught it to be incurable. Hernia is barerly
mentioned in the writings of
Hippocrates(500BC).
The evolution of surgical hernia
encompasses the trials and errors of surgeons
practicing their art during the past 22
centuries.Most of the evidence obtained from
historical documents suggest that throughout
the ages till the onset of 19 th century the
mainstay of treatment of hernia has been
conservative and the evolution of surgical
treatment is closely paralled that of surgery.
3500 year ago,Egyptian Physicians
reported the management of hernia by
conservative means that included the snugly
fitting bandage for reduction and support.
 The treatment of taxis for irreducible hernia
has been traced back twenty four hundred
years.The earliest mention of inguinal hernia is
found “eber’s papyrue”(1500BC)in which it
is apperent that the pre-homeric treated the
inginal hernia is by conservative methods.
Aurelius Celsius:the greek encylopediast
and surgeon emigrated to rome documented in
(5AD)in the use of transillumination to
distinguish hydroceles and described taxis for
strangulation.trusses and bandages were used
for reducible hernia.
An operation was adviced for pain specially
in the youngs.the first description of an
operation included incision of the scrotum just
below the pubis with removal of hernia
sac(“kelotomy”) and the testis.The wound
then allowed to granulate,scar tissue was
perceived as the optimum replacement for
stretched abdominal wall.the concept of
repture came from “galen”(200AD)who
without dissecting the human body conceived
that herniation was produced by ruptured of the
peritoneum with stretching of overlying fascia
and muscles.
 Paul of Aegina(700AD)was the last of Greek
Writer.He distinguished between incomplete
Inguinal(bubonocele) and complete
form(scrota).
Post Renaissance Period (Period Of Surgeon –
Anatomists)[84,94]

After the renaissance, Autopsy and anatomic

dissection spread throughout the Europe.
Started in Bologna in 1200 AD, knowledge
about herniation accumulated rapidly. In 1700
Littre reported Meckel diverticulum in hernia
sac, “Williem Cheselden” successfully
operated on strangulated hernia in 1721.
Ronsil (1724) reported obturator hernia. De
gorengeot in 1731 described lumbar herniation
as well as herniated appendix. Hunter (1978)
and Percival Pott of London pointed out the
congenital nature of some indirect inguinal
hernia.
In 1731 Gimbernat described the ligament
that bears his name and advocated its division
in instances of strangulated Femoral hernia
rather than upward incision of the Poupart
ligament which occasionally led to serious
bleeding from on aberrant course and inferior
Epigastric artery.
‘Antonio Scarpa’ (1752 – 1832) Author and
treatise on hernia’s which was published in an
English translation in 1814. In his treatise Scarpa
described accurately based on autopsy studies
the sliding hernia.
“Astley patson Cooper”[48](1768 – 1841) the
study pupil of John Hunter whose great interest
was in the study of hernia, Breast, and Arterial
surgery. In his treatise on hernia published in
London in 1804 and 1807. Anatomy and surgical
treatment of abdominal hernia published in
1844. Cooper described for the first time the
superior pubic ligament, which bears its name
and transversalis fascia with full recognition of
its role in the pathogenesis of hernias.
Frenz Casper Hasselbach[48](1759 – 1816)
Remembered primarily for his Anatomic studies
relative to groin hernia Eponyms include
triangle (an Anatomic space bounded by
inguinal ligament, the medial margin of rectus
muscle and deep or inferior epigastric artery).
Jules German Cloquet (1970 – 1883)[48]
allegedly dissected and sketched 345 cases of
hernia. He also pointed out that the peritoneum
is actually displaced and not ruptured in the
formation of hernia sac. He described the
processus vaginalis rarely closed at birth.
Despite these important advances and the
introduction of Anesthesia in 1846 Surgical
repair made a little progress in the first half of
the 19th century, since any attempt to open the
inguinal canal was followed by severe sepsis
and recurrence of the hernia.

PERIOD OF ASEPTIC SURGERY, 19TH AND 20TH

CENTURIES[48]
In 1867 Joseph Lister a Professor of
Orthopedic Surgery at Glasgow infirmary
presented his first paper concerning, antiseptic
surgery performed under carbolic acid spray.
Prior to Lister all hernia repairs were performed
through the external ring incision of fascial
planes was scrupulously avoided in order to
prevent what usually happened anyway.
Ubiquitous infection and its dare
consequences.
Marcy, Lister’s pupil, in 1871 published the
first article in United States on Antiseptic
herniorrhapy using carbolised catgut ligature. In
1877 Czerny, Lister’s pupil in Germany
described pulling the sac down through the
external ring and excising, it allowing the ligate
neck to retract and invest at the internal ring.
 In 1869 Mc Ewan first recognized the
importance and the role of transversalis fascia
in the repair of hernia. Mc Ewan created a
baffle of the preserved sac and used it at the
same time, he obliterated the inguinal canal
ring using mattress suture. The 1880 – 1890
the period in the last century could justifiably be
termed as the “Decade of Inguinal Hernia”,
significant contributors included Lucas
championniere, Marcy, Bassini. Another of
Listers’s student from France Lucas-
championniere who introduced antisepsis to
France. In 1885 incised the external oblique
aponeurosis, lay open the inguinal canal and
imbricate the roof in the closure.
However the credit of modern heniology
should be given to Marcy of United states in
(1837 – 1924) a pupil of Lister, Marcy was first
to indicate the importance of the high ligation of
hernia sac and closure of dilated inguinal ring
as essential steps in the repair of inguinal
hernia and the first to describe the
transabdominal approach. This operation
performed by Marcy in 1869 and reported in
1971 predated Bassini by almost – 15 years.
 In 1890 Billroth and Bull separately reviewed
the literature on herniotomy and published their
results. It was noted that though the mortality
and rates had remarkably came down
compared to the prelisterian era. The
recurrence rate was disturbing, amounting to
30 – 40% in one year and almost 100% within
four years.

Edoardo Bassini (1844 – 1924)[79] of Pavia of Italy

revolutionized the treatment of inguinal hernia
by the introduction of a technique designed to
restore those conditions in the area of hernia
orifice which exist under normal circumstances.
In 1890 he published his epoch making report
on 206 cases of hernia operations with very low
mortality and recurrence rates. He initiated the
use of transversalis fascia, rectus sheath and
interrupted silk suture. He did bilateral repairs
and management of cryptorchidisim in same
sitting. Just over a century ago
Bassini[108],ignoring the surgical convention of
his day,took a new approach to inguinal hernia
repair.He developed an anatomic
reconstruction of the inguinal floor that quickly
became the standard by which other new
approaches would be judged.Despite multiple
modifications of his original approach by
surgeons attempting to simplify or improve on
his technique,recurrence rate generally
remained fixed at the 10% level that he first
reported in 1887.
Not until 20th century surgeons analyzed the
mechanisms that cause hernioplasties to fail
did a new approach evolve that would radically
reduce the incidence of recurrence.Surgeons
began to focus on reducing the tension created
by conventional repairs and bolstering the
intrinsic weakness of the groin floor,two of the
prime causes of recurrence.
Willium. S. Halsted(1852 – 1922) independently
developed a similar procedure with few
differences which included the complete
excision of all three musculoaponeurotic layers
there by reforming the internal ring and
transplantation of the cord to a subcutaneous
position and debulking the cord. This was
called the Halsted I procedure to distinguish
from the Halsted II42 procedure. (Also known
as Ferguson – Andrew’s procedure), where
cord was kept alone as per Ferguson and
external aponeurosis imbricated as per
Andrews.
Bassini’s procedure was adopted widely,
but modifications were rapidly introduced.
Halsted and his assistant Blood Good like
Bassini concerned about the strength of the
repair medially at the pubic angle especially
when the conjoint tendon was atrophic. They
sutured the adjacent rectus muscle but
adopted the anterior relaxing incision.
Mc vay and Anson pointed out in 1940 that
the rectus fascia is a portion of the transversalis
fascia that inserts in to the lateral border of
rectus muscle, is strong enough to prevent
incisional herniation. Ponka (1968), Credited
Farr (1927), Fallis (1938) continued the use of
relaxing incision which has been popularized by
Mc vay in 1966 and Halverson in 1981.
The Era of Tension Free Hernioplasty
Inguinal hernia repair is one of the most
common surgical procedures.In the United
States alone,more than 700,000 of these
procedures are performed each year,incurring
approximately 3.5 billion dollars of hospital
costs[20].Optimizing surgical technique to
improve short term outcome and reduce the
rate of recurrence is therefore of great value to
health care.
The introduction of Lichtenstein tension-free
hernioplasty,which uses a mesh to reinforce
the abdominal wall,has decreased recurrence
rates greatly[21K].Another advantage of the
Lichtenstein hernia repair is that it is a relatively
straightforward and easy to learn procedure
requiring minimal dissection that can be
performed using local anaesthesia. In
addition,because the technique is tension
free,it is associated with significantly less post
operative pain and discomfort than
conventional open repair[21K].
The Cochrane database review 2002[106]
compared twenty trials comparing open mesh
with open non mesh repair were
identified.Open mesh methods,on average took
7-10 minutes less to perform than Souldice
procedures,but took 1-4 minutes longer than
other non mesh methods.There were no clear
differences between mesh and non mesh
groups for hematomas,seromas or
wound/superficial infections.Three serious
complications were reported after open mesh
repair and three following non mesh
repair.Overall,those in the mesh groups had a
shorter length of stay and quicker return to
usual activities,but this pattern was not
observed for all trials.There was a suggestion
that persisting pain was less frequent after
mesh repair than after non mesh repair but this
result was dependent on one trial and data
were not available for 11 trials.There was no
evidence between the groups with respect to
persisting numbness.Fewer hernia recurrence
were reported after mesh repair(Peto
OR:0.37,95%CI:0.26 to 0.51).
DARN REPAIRS : Mc Arthur in 1921 used the
pedicled strips of external oblique aponeurosis
woven between the conjoint tendon and
inguinal ligament.
Gallie and Le-mesurier in 1921 published the
use of fascia lata strips used as sutures woven
in to the muscles and the inguinal ligament and
the tissues of the posterior wall of the inguinal
canal “Much as one would darn sock”. Pratt
in 1948 used steel wire followed by koontz in
1950 tantalum gauze.
In 1948 Moloney introduced the forerunner
of the modern nylon darn
technique. The basic principle of hernia repair
were laid down in late 19th century and
modifications were made in Bassini’s
procedure with local anesthesia being
advantageously used.
Local anesthesia for repair of hernias reported
by Harvey Cushing at the end of the century.
He used cocaine infiltration. Two major
techniques that have proved to be done
effectively under local anesthesia,the Canadian
Shouldice repair and Lichtenstein tension free
hernia repair.

PATCH GRAFT REPAIRS :

Whenever the local tissues were weak and
attenuated approximation of tissues is under
tension. The sutures did not hold and the hernia
recurred, so the surgeons thought of the
exogenous or endogenous prosthesis of good
tensile strength. To start with, patch in the form
of sheets of natural tissues and biological
materials or synthetic sheets to fill the gap in
the posterior wall of the canal. Silver wire mesh
were used first in most of the cases were
corroded, fragmented and were rejected
through chronic sinuses and leads to
recurrence.
In 1940 Burke introduced tantalum metal
sheets, but due to fragmentation of metals
hernia recurred. Surgeons started getting
sheets of natural tissues flaps from fascia of
thigh. Aponeurosis of external, internal oblique
or rectus sheath were turned down and sutured
to inguinal ligament. Mair in 1943 used skin
graft. In the early 1970s,Read [69]
demonsterated that collagen weakness was in
great part responsible for the ultimate fate of
inguinal hernia repairs.He suggested that the
use of prosthetic material for inguinal
herniorraphy be studied.During the same
period,in 1958 Usher[69] introduced a radically
new approach using polypropylene mesh to
repair the wall and reinforce previously sutured
repair..
More than 20 yrs later,Lichtenstein[62],despite
the skiepticism voiced by his surgical
colleagues,emphasized the importance of
prolein mesh as a means of creating a
“tension free repair”.He and his colleagues
ultimately demonstrated that the use of mesh
to repair the hernia defect was not only safe,it
was also an effective way to decreasing the
incidence of recurrence to <1%.
During approximately the same period,other
surgeons were developing a posterior mesh
approach to address the causes of hernioplasty
failure.Not only was the posterior repair
designed to eliminate tension and reinforce a
potentially weak wall,it was also practical for
even the most complicated hernias-those that
were already recurrent .Stoppa[102],Nyhus et
al.[81],demonstrated that a tension-free repair
could be successfully completed from behind
the hernia,avoiding the confusion of scar tissue
created by any previous operation.
A variety of much designs and much
placements have flourished since Lichtenstein
showed that much could be used for
successfully in 1947 by plug repair for femoral
and recurrent inguinal hernia and in 1986 as
only mesh patch as primary hernia repair. In
1991 Gilbert’s suture less repair of small to
moderate sized by inguinal hernia cones and
swatch, i.e. a suture less patch may be placed
over the whole of the posterior inguinal wall to
reinforce this “Swatch”.
The roll of material is placed in the hernia
orifice with or without suture to obstruct the
passage of hernia to the exterior, popularized
by Robbin and Rutkow in 1993. Expended
polytetrafluroethylene has been adopted for
both the external and preperitioneal approach
with good results. In recent years sheaths of
woven monofilament polyamide or knitted
monofilament polypropylene have been used
extensively.
Recently a bilayer patch[27] device for
inguinal hernia introduced. The unique feature
of this polypropylene mesh device is that it has
three components. Its underlay patch provides
posterior mesh repair. Its connector has the
desirable attributes of the plug repair. Its only
patch covers the posterior wall up to inguinal
ring.
PREPERTONIAL REPAIRS
The early history of the posterior approach
to groin hernia is interesting. Thomas
Annandale of Edinburgh presented for the first
time in 1876 the concept of the preperitoneal
approach.

‘Lawson Tait’ of Birmingham, England in

1883reported the advantage of the treatment of
hernia by median abdominal section. Bates
(1913) Repaired the defect from the posterior
approach using transversalis fascia.
‘Cheatle’ (1920) renewed interest in the
preperitoneal approach. ‘Henry’ in 1936
suggested that the approach might facilitale the
technical handling of inguinal and femoral
hernias. This approach was strongly
recommended by ‘Nyhus’ in 1960.
Undoubtedly the foremost proponent of
today’s preperitoneal approach is Stoppa who
recommends it especially for problematic case
in which repeated repairs of Multiple recurrent
hernia have been done and in which tissues
have become scarred and weakened and the
normal anatomy destroyed.
Despite the evolution of new techniques that
potentially reduce the incidence of
recurrence,the overall recurrence rate for
hernia repairs in the United States remains at 5
-10%[73],except in isolated centers that
specialize in hernia repair[26].In most
settings,patients recovering from a hernioplasty
still require several weeks to return to normal
activities and work[26].In early 1990,not
satisfied with this lengthy recovery period and
such high recurrence rates,some surgeons
attempted to incorporate the principles of
posterior mesh repair with a new,evolving
surgical technique-Laparoscopy.
LAPROSCOPIC INGUINAL HERNIAL REPAIR[87,93] :
The optimal method of providing durable low
morbidity repair of inguinal hernia remains a
matter of contention. The wave of minimal
access surgery has inevitably swept hernia
repair along its surge.
In 1982 via laparoscope Ger and his colleagues
used Michel staple applied with a Kocher clamp
to close peritoneal opening of the hernia sac. In
1989 Bogojavlensky reported filling an indirect
hernia defect with plug of polypropylene mesh
followed by laparoscopic suture closure of
internal ring.
In 1990 Popp reported hernia repair during the
uterine myomectomy. In Minnesota, Schultz
conducted a first large series of Laparoscopic
herniorrhapy. The early results reported by
Shultz et al. [73] were interesting but
disappointing.Although they were successful in
controlling the hernia in 75% of cases,this early
technique missed elements of complex hernia
in one-fourth of patients,resulting in early
recurrences in this group.A followup series in
which the entire posterior floor was dissected
and repaired,however,eliminated missed
hernias,thereby avoiding early recurrences[73].
In 1991 Arregui described the transabdominal
preperitoneal approach with full Exposure of
the inguinal floor and placement of large pre
peritoneal prosthesis. In 1992 Mc Kernan and
Laws described totally extraperitoneal
technique which avoids peritoneal cavity.
Surgeons using either a transabdominal
preperitoneal or a totally extraperitoneal
laparoscopic approach have reported
recurrence rates between 0.5% and 2% for
patients undergoing either primary or recurrent
laparoscopic repairs[26,55,73].However,other
investigators have failed to achieve similar
results[21,27,78].The recurrence rates in their
patients have either been as high or higher than
traditional repairs.The amount of experience
the surgeon has with this new approach may
be the key.Even the Shouldice repair,which is
now repor to have a 1% recurrence rate,had an
initial failure rate of 17%[80].
In Phillips et al.`s review[89],20% of
recurrences were due to missed
hernias;again,the operating surgeons had
limited laparoscopic experience.No missed
direct hernias occurred after the TEP
repairs.This universal success can be explained
partially by the level of experience achieved by
most surgeons before performing their first
totally extra peritoneal procedure and partially
by the fact that the direct floor was
automatically dissected by a balloon dissector
or laparoscope when the extraperitoneal
exposure was achieved.
However,the TEP approach was not immune to
its own form of missed hernia.A retained or
missed lipoma was responsible for one –third
of the TEP repairs that failed.When performing
a totally extra peritoneal dissection,the
surgeons may overlook a lipoma if there is no
indirect hernia is quite small.Care must be
taken to clear the iliopubic tract in order to
ensure the removal of any extra peritoneal fat
that may be draping over the internal ring into
the canal.[35]
The size of mesh used to cover the posterior
wall is crucial in these laparoscopic repair.If it is
too small,there is inadequate surface area to
resist the pressure on the mesh and a recurrent
hernia will develop.In Phillips et al.`s report of
laparoscopic failures,60% of recurrences were
due to the inadequate size of the mesh.[89]
Inadequate lateral fixation of mesh was one of
the major causes of failure in both approaches-
36% of TAPP and 22% of TEP repairs.Because
of the location of major nerves,fixation cannot
be done below the iliopubic tract.the mesh is
therefore vulnerable to being elevated off the
lateral wall,which results in an indirect
recurrence.In the TEP repair,there may be a
tendency not to dissect the peritoneum far
enough off the cord structures to allow the
mesh to lay under the peritoneum.
To prevent lateral recurrences,several surgeons
utilized a keyhole in the mesh that placed it
under the testicular vessels and vas
deferens.The keyhole,however,was responsible
for 15% of all recurrences and one-third of the
TEP failures.An additional mesh over the
keyhole placed in some of the repairs may have
prevented this number from being even
higher.Stoppa found the slit in the mesh to be a
cause of concern in his open posterior repair
and no longer recommends slitting the mesh in
order to prevent herniation through it[102].
Stoppa and others have shown,recurrences
after posterior mesh repairs rarely occur after
the 1st year of follow-up[102].The laparoscopic
repair is successful because it allows the
surgeon to avoid missed hernias,reduce
tension, and buttress any intrinsic collagen
deficits[73].The depth of experience of the
surgeon,however,is the key to its success.
DAY CARE & SHORT STAY SURGERY FOR HERNIA
[5,15,28,31]
Harvey Cushing described hernia repairs
under local anesthesia using cocaine in 1900.
Earnest Trice In 1947 described groin hernia
repair under local anesthesia with ambulation
of the patient from the operating table. During
the World War II with the shortage of hospital
beds Trice sent many hernia repair patients
back home on the
day of surgery without any increased mortality
and morbidity. Shouldice clinic performed more
than 10,000 repair under local anesthesia on
day care basis with immediate ambulation.
Laparoscopic Versus Open Tension free
hernioplasty-The Debate continues.
Since the introduction of laparoscopic inguinal
hernia repair,most of the ongoing discussion
has focused on the choice between open or
laparoscopic surgery. Laparoscopic inguinal
hernia repair is associated with shorter
recovery periods,earlier return to daily activities
and work,and fewer postoperative
complications[17].Some authors suggest that
laparoscopic repair of recurrent hernia is easier
because it is performed in virgin tissue.
On the other hand, laparoscopic hernia repair
requires special skills to overcome limitations
inherent to this type of surgery such as loss of
depth perception,limited range of motions,and
reduced tactile feedback.As a consequence,
laparoscopic hernia repair has a significant
learning curve[27] and is associated with longer
operating times[27,73].
Furthermore,some serious complications
during laparoscopic TAPP mesh repair have
been reported[89,51,11],some even resulting in
the death of a patient[89].Some authors
propose that these complications may have
been avoided if a laparoscopic TEP approach
had been used[89,51].
Several Guidelines are available for the
treatment of hernia like NICE,Royal
College,European,Dutch,Clearing house,SSAT
etc.In the era of “Evidence based
Medicine”,practice of hernia surgery has been
a major area of research.
Evidence is graded as follows:
Ia - Meta analysis of randomised controlled
trials(RCTs)
Ib –At least 1 RCT
IIa - At least 1 Non randomised study
IIb - At least 1 other well designed quasi experimental
study
III – Non experimental descriptive studies
IV- Expert committee reports or opinions/experience
of respected authorities
NICE(National Institute for Clinical Excellence)
is charged with providing the National Health
Scheme(NHS) in England and Wales with
independent advice on the efficiency and cost
effectiveness of selected health technologies
and procedures.
NICE 2001 guidelines stated that first time
hernias of the groin ought to have open repairs
and the laparoscopic TEP repair should only be
considered for bilateral and recurrent hernias
and be performed in specialist units.
NICE guidelines released September 2004[70]
replaced the old one.these are:-
1) Laparoscopic surgery is recommended as
one of the treatment options for the repair of
inguinal hernia.
2)To enable patients to choose between open
and laparoscopic surgery(either by the
transabdominal preperitoneal[TAPP]or by the
totally extraperitoneal[TEP] procedure),they
should be fully informed of all of the risks(for
example,immediate serious complications,
postoperative pain/numbness and long-term
recurrence rates)and benefits associated with
each of the three procedures.
In particular the following points should be
considered in discussions between the patient
and the surgeon:
• The individual`s suitability for general
anaesthesia
• The nature of the presenting hernia(that
is,primary repair,recurrent hernia or bilateral
 hernia)
• The suitability of the particular hernia for a
laparoscopic or an open approach
• The experience of the surgeon in the three
techniques.
3) Laparoscopic surgery for inguinal hernia
repair by TAPP or TEP should only be
performed by appropariately trained surgeons
who regularly carry out the procedure.
Society of Surgery of the Alimentary Tract
(SSAT 2003) Recommendations
“Most groin hernias can be electively
repaired.Urgent repair is required for an acutely
non-reducible hernia or for a chronically
incarcerated hernia that suddenly becomes
painful,as this indicates impending
strangulations.While significant morbidity and
mortality can be avoided by prompt
diagnosis,this clinical emergency causes the
death of more than 2,000 patients per year in
North America.
Inguinal hernias should be repaired
surgically.Hernias belts or truss should be
limited to patients who are not candidates for
an elective operation.Cronic scarring from their
use can lead to a more difficult repair and
higher risks of complications.Elderly patients
with minor co-morbid conditions will easily
tolerate an outpatient elective hernia
repair,which can be accomplished with
intravenous sedation and local anaesthesia.All
attempts should be made to avoid emergent
repairs of chronically incarcerated
hernias,which occur primarily in the elderly.The
timing of repair is determined by the symptoms.
The objective of any inguinal or femoral hernia
operation is to repair the defect in the
abdominal wall.The three basic approaches
are:
(1)Open repair(the traditional repair,utilizing the
patients own tissue);
(2)Open tension-free repair(in which mesh is
used to bridge or cover the defect);and
(3)Laparoscopic repair,a tension-free repair
also utilizing mesh.
In general,the traditional,tissue-based repairs
have been replaced by tension-free or mesh-
based repairs.These include the
Lichtenstein,plug-patch, Laparoscopic,and
“hybrid” techniques.No particular techniques
has been found to be superior,and all of them
can be expected to result in excellent outcomes
when performed by adequately trained
surgeons with sufficient experience in their
performance. Open techniques of hernia repair
may be safely performed under
local,regional,or general anaesthesia with
equivalent outcomes.
Some selected hernias can be treated
nonoperatively with careful
observation.Suitable hernias for nonoperative
management are direct hernias with a wide
neck that easily reduces particularly in elderly
asymptomatic patients or patients at a
heightened risk for operative intervention.The
qualifications of the surgeon should be based
on training(education),experience,and
outcomes.”
Level Ia evidence-Meta-analysis and
Systematic Reviews
Because of the intense debate on the best
hernia repair and the numerous articles
compairing laparoscopic and open hernia
repairs,there has been an attempt to
summarize the literature and to develop an
overall conclusion to the numerous
publications.
There have been meta-analyses and
systematic reviews attempting to determine the
best repair. Chung and Rowland in 1999
performed a meta-analysis of 14 studies with
2471 patients comparing laparoscopic and
open repairs. They found a modest advantage
with the laparoscopic approach compared with
open mesh repairs however there was no
difference in pain . Compared with the open
non mesh repaires, there was less pain. Return
to activity was quicker with the laparoscopic
approach, although it was more difficult to
perform, took longer and recurrences were the
same[19].
Grant in 2000 performed a systematic review
of 34 trials with 6804 patients comparing
laparoscopic and open repairs. There was less
pain and quicker recovery with the
laparoscopic approach. Overall complication
were similar in the two groups but there was a
higher incidence of rare but serious
complication. As in chung and Rowland’s
meta-analysis the laparosopic repair took
longer and
Recurrences were no different[43].
The European Union trialists updated their systematic
review of 2002 by collating individual date on
4165 patients in 25 trial to perform a meta-
analysis. The laparoscopic group returned to
normal activity faster, persistent pain was less
and recurrence was less than with open
nonmesh repair but the same as for open mesh
repair. As in the earlier systematic review they
found that laparoscopic approach takes longer
and that there were more serious complication
with it[42].
Veterans Affairs Hernia study- The united states
veterans affairs cooperative studies program
456 [78] stated that open mesh repair is
superior to the laparoscopic approach. This
multi institutional randomized prospective study
with a 2-years follow-up primarily looked for
recurrences and secondarily looked for
complication and patient outcomes.
The laparoscopic approach resulted in less pain
for up to 2 weeks and quicker recovery. These
finding are similar to the conclusions of the
above-mentioned meta-analyses and
systematic reviews. Complications in this study
were higher for the laparoscopic group (39.0%)
then for the open mesh repair (33.4%),and
recurrences were likewise higher for the
laparoscopic group (10.1%) then for the open
mesh group (4.9%). This is contrasted with the
finding of no difference in meta-
analyses,systematic reviews,and most previous
and current studies.

The laparoscopic approach was batter regar

ding recurrent hernias. There were fewer
recurrent hernias in the laparoscopic group
(10.0%) then in the open mesh group (14.1%).
The laparoscopic group did even better when
highly experienced surgeons alone were
evaluated. In this subgroup of recurrent
hernias,the laparoscopic approach had 3.6%
recurrence versus 17.2% for the open mesh
repair. These were many flaws in this study like
difference in experience of surgeons
performing open and laparoscopic repairs,non
standardization of TEP and TAPP repairs with
different sizes of meshes used.
Randomized clinical trials comparing only TEP
repair with open repair are scarce. Although
many surgeons have now adopted the TEP
repair,reviews and meta analyses published to
date are based primarily on comparisons
between both laparoscopic TEP and TAPP
repair with open inguinal hernia repair[73].
Results of a recent Systemic Review by Khoury et
al[55] of 23 trials published comparing
laparoscopic TEP repair versus open repair are
as follows. It included a total of 4,231 patients.
The follow-up periods ranged from 0 to 48
months. These results are:-

Oprating Time- Data on the duration of surgery

were compared in 15 of the trials. The TEP
repair required significanty more time then the
open methods of inguinal hernia repair in 10 of
the trials. One trial reported a shorter operating
time for TEP repair than for Lichtenstein
hernioplasty. For three trials,no significant
differences were found.(Table 2).
Hospital stay- in-hospital stay was mentioned
in available data on 11 trials. Significant
differences in favor of TEP repair were found in
six trials. Heikkinen et al.[44] found a longer
hospital stay after TEP repair then after
Lichtenstein tension-free hernioplasty(6.25 vs
4.75 h; p < 0.001). In two trials,no differences
between groups were found ,and in one study,
p values were omitted(Table 3).
Major complications- only one major
complication,a bowel obstruction, was reported
among the patients undergoing TEP repair
within the framework of a randomized
trial[107]. Among the patients undergoing open
surgery, no major complications occurred
during or after the surgical procedure.
Return to work- In nine trials, return to work was
compared between TEP and open repair. In
eight of these trials, TEP repair was associated
with significantly fewer workdays lost then
open repair(Table4).
Recurrence rates- Recurrence rates were
reported in 15 trials. Liem et al. [63]reported a
significantly lower rate of recurrence after TEP
then after various methods of open mesh and
open nonmesh repair (p= 0.006). In the
remaining 14 trails, no significant differences
were found(Table5).
Table 1. Datails on articles and abstracts
regarding randomized controlled trilas
comparing open repair and laparoscopic TEP
repair of Inguinal hernia.

Reference type of open repair follow-

up(MONTH) No analyzed

1) Heikkinen et Lichtenstei 10(median) 45

al.[44] n
2) Andersson et Lichtenstei 2(97%) 168
al.[2] n
3) Merello et Lichtenstei “short” 120
al.[75] n
5) Lal et al.[56]
Lichtenstei 13 (mean) 50
n
6) Payne et Lichtenstei 20 (median) 100
al.[88] n
7) Colak et Lichtenstei 12/11 (mean)* 134
al.[20] n
13) Khoury et Mesh- 17 (median) 292
al.[52] plug
14) Bringman et Lichtenstei 20(98%) 294
al.[14] n, Mesh-
 plug

TEP vs open mixed

1)Liem et al.(63) Procedure of choice 20(median) 994

2)Liem et al.(63) Procedure of choice 1.5 105
3)Liem et al.(63) Procedure of choice 20(median) 237
4)Liem et al.(63) Procedure of choice 44(median) 994
5)champault et Shouldice , stoppa (79%mean) 461
al.(17) 48
6)Wright et Lichtenstien,stoppa 60(mean) 300
al.(109) & others
7)Vatansev et Lichtenstien, 0.25 84
al.(109) Bassini, Nyhus

Table 2 operating time

Reference TEP OPEN P Value
Heikkinen et al (44) 67.5(40-88)* 53(42-78) 0.001
Andersson et al.(2) 81±27 59±20 <0.001
Bilgin et al (9) 69(25-150)⌃ 85(40-150)⌃ not stated
Lal et al (56) 75.7±31.6 54±15 <0.001
Colak et al.(20) 49.67±14.11 56.67±11.67 0.002
Bostanci et al. (13) 58(40-85) 35(20-65) <0.05
Suter et al.(104) 82(50-135)⌃ 54(35-86)⌃ <0.001
Khoury et al.(52) 31.5(5-80)* 30.5(10-70)* NS
Bringman et al.(14 ) 50(25-150)⌃ 36(19-88;45(24-100)⌃-<0.001
Wright et al.(112) 60(53-72)* 45(35-52)* <0.0001
Liem et al.(63) 45(35-60)* 40(30-45)* <0.001
Vatansev et al.(109) 58.6±9.7 54.7±7.2;51.9±6.5;59.4±8.2
NS
Decker et al.(23 ) 57.2(38-78)⌃ 53.1(33-71)⌃ NS
Fleming et al.(36) 70(30-145)* 56(30-145) <0.0001
Simmermacher et al.(107) 27⌃ 39⌃
<0.001
*median(range);⌃mean(range);_ mean±standred deviation
- mesh-plug ;lichtenstein – signification difference between
TEP\lichtenstein versus mesh plug Lichtenstein ;Nyhus;

Most of the randomized trials reported longer

surgery time for TEP than for open repair .
Possible reasons for these prolonger operative
times are the intricacy of the procedure and the
need for general anesthesia. A major drawback
of the laparoscopic approach for inguinal
hernia repair is the risk of major complication.
The TEP procedure for hernia repair is
performed within the prepreitoneal space. The
peritoneal space is avoided presumably leading
to aconsiderable reduction in the risk of major
vascular complication intestinal obstruction,
and perforations.
In this review, only one major complication was
reported among the patient undergoing TEP
hernia repair[107]. This patient experienced a
small bowel obstruction 3 days after surgery. A
loop of the small intestine had herniated
through a peritoneal tear. These peritoneal
defects occur in approximately 10% to 47% of
laparoscopic hernia repairs[16,109,54].
However, herniation occur rarely and can be
pervanted by closing the peritoneal defect for
example, throught the use of laparoscopic
stapling or pretied rsuture loop ligation[58].
Proponents of laparoscopic inguinal hernia
repair often refer to the shorter hospital stay
and the earlier return to daily activities and
work associated with the approach. Obviously,
hospital stay and return to work are very
important outcome measures given that many
patients who undergo inguinal hernia reapair
are of working age. The majority of trials in the
current review showed earlier hospital
discharge and quicker return to work after TEP
than after open hernia repair.
In a systematic review by the hernia trialist
collaboration [80],which included mainly trials
comparing TAPP with open procedures,no
significant difference in length of hospital stay
was observed between groups (p
=0.50).however, return to normal daily activities
was found to be earlier after minimally invasive
surgery (p <0.001). the economic benefits to
society of reduced absence from work are
clearly indicated by the differences in direct
and totals costs. Whereas in-hospital costs are
significantly higher for TEP than for open hernia
repair , no differences exist in total costs,
including costs associated with workdays lost.
Table 3. hospital stay

Reference Hospital stay

TEP open p value

Heikkinen et al. [44] 6.25(5.25-21)* 4.75 h (1.75-45)* <0.001

Andersson et al.[2] 13.6±6.9 h 12.4±6.3 h NS
Bilgin et al.[9] 1.3days(1-4) 3.2days(1-7) not stated
Lal et al.[56] 1.48days(1-2) 1.40days(1-2) NS
Colak et al.[20] 1.80±0.65days 2.73±1.62days 0.001
Champault et al. [16] 3.2 days(1-6) 7.3days (5-12) 0.01
Suter et al.[104] 2.2(2-4) 2.7(2-4) 0.02
Khoury et al.[52] 100% daycare 98%daycare NS
Wright et al.[40] 1 day (0-1)* 2 days (1-2) <0.0001
Liem et al.[63] 1 day(1-2)* 2 days (1-2) <0.001
Fleming et al.[36] 68%daycare 48%daycare 0.0065

*median (rang); ⌃mean (range)

- mean ± standerd deviation

Table 4. Return to work

Reference Return to work
 TEP
Open p value
Heikkinen et al. [44] 12(3-21*) 17(4-31)* 0.01
Andersson et al.[2] 8±5_ 11±8_ 0.003
Merello et al.(75) 11⌃ 26⌃ not started
Lal et al. (63) 12.8±7.1_ 19.3 ± 4.3 < 0.001

Champault et al. [16] 17±11 35±14 0.01

Khoury et al.[44] 8(5-13)* 15(11-21) 0.01
Bringman et al(14). 5(0-30)* 7(0-150); 0.02
Liem et al. (63) 14(7-21)* 21(12-33)* 0.001
Fleming et al.[36] 14(3-42)* 30(7-84)* 0.0001

*median (range); _mean ±standred deviation

- Mesh-plug ; Lichtenstein
_ Signification different between TEP and
Lichtenstein repair only
Table 5. Recurrences
Reference Recurrences
TEP Open
P value
Heikkien et al. [44] 0/22 0/23
NS
Andersson et al.[2] 2/78 0/85
NS
Merello et al.[75] 0/60 0/60
NS
Bilgin et al.[9] 1/30 0/30
NS
Lal et al.[56] 0/25 0/25
NS
Colak et al.[20] 2/67 4/67
NS
Bostanci et al.[13] 0/32 0/32
NS
Champault et al.[16] 3/51 1/49
NS
Suter et al.[104] 1/20 0/19 NS
Khoury et al.[52] 3/150 4/152 NS
Bringman et al.[14] 2/92 2/104;0/103- NS
Liem et al.[63] 21/487 43/507 0.006
Champault et al.[16] 7/107 8/64;2/19_ NS
Wright et al.[112] 3/149 3/151 NS
Fleming et al.[36] 2/93 5/106 NS

Although laparoscopic TEP hernia repair is more

expensive for hospitals, it appear to be cost effective
for society as a whole. However, long term
recurrence rates and morbidity have not been
included in the economic evaluations performed to
date.
In a recent metaanalysis of randomized trials
comparing open and laparoscopic inguinal hernia
repair[73], a trend toward an increase in the relative
probability of short term hernia recurrence after
laparoscopic repair was detected. However this
trend was found only for TAPP compared with open
hernia repair and not for trials compairing TEP with
open hernia repair. None of the differences
observed were statistically significant.
In the current analysis of 23 trials comparing TEP
repair with open mesh and sutured repairs, only one
trials reported a significant difference in the number
of recurrence[65]. Among 994patients undergoing
inguinal hernia repair, a lower recurrence rete after
TEP than after open repair using various techniques
was observed (21/507 vs 43/487; p =0.006). none of
the other trials showed any significant differences in
recurrence retes between the different techniques. A
possible reason for this is that these trials were not
adequately powered to detect singnificant variances
of this magnitude. Future large trials may show up
such differences, which are not apparent in most of
the studies analyzed in the current review.
Neumayer et al.[78] compared both the TEP and
TAPP repair techniques with the open lichestine
method and concluded that the open technique is
superior to the laparoscopic technique for mesh
repair of primary hernia. TEP repairs tends to be
superior to TAPP repair, because of less morbidity as
well as lower recurrence retes and
complications.[59]
TEP repair seems to be associated with longer
surgery time, shorter hospital stay and earlier return
to work than open inguinal hernia repair. Although
TEP is associated with higher hospital costs, it does
not seem to produce an increase in total expenses
including costs of sick leave. Recurrence rates after
TEP repair seem to be compairable with, if not better
than, rates after open methods of repair.
Table 6. qualitative analysis
Outcome No of trials
significant advantages*
TEP TAPP
Duration of 15 10 1
operation
Hospital stay 11 6 1
Return to work 9 7 1
Recurrence 15 1 0
*p<0.05
A recent metaanalysis by schmedt et al[100] carried
out a quantitative analysis of the following
parameters: operating time, intra and postoperative
total morbidity,intestinal lesions, urinary bladder
lesions, lesions of major vessels, wound infections,
hematomas, seromas, urinary retention, time to
return work, inguinal paresthesia, and long term
complications such as chronic pain, testicular
problems, and hernia recurrence.
The meta analysis was made up of two parts: (a) a
comparison of the laparoscopic techniques
(TAPP/TEP) vs the lichestein repair (23 trials
including 4550 patients) and (b) a comparison of
laparoscopic techniques (TAPP/TEP) vs other open
mesh implant techniques (non lichestein) (11 trials
including 2673 patients).
Operating time- The analysis of operating time
yielded a mean oprating time of 65.7 min (ranges 40
-109) using TAPP/TEP and 55.5 min (ranges 34-99)
using the lichestein repair; thus, the laparoscopic
techniques take a significantly longer time.
Total morbidity- The meta-analysis of total morbidity
indicated that there was no differences between the
laparoscopic techniques (TAPP/TEP) (638 of
2250,(or 28.4%)and the lichestein repair (652 of
2300,(or 28.3%) (p=1) 1.00 [0.87, 1.14]). This result
was strongly influenced by the veterans affairs
multicenter trial[78]; if these data are excluded, a
significantly higher total morbidity found for the
lichestein repair. The meta analysis of studies
comparing laparoscopic repair with other open mesh
techniques revealed that a morbidity is significantly
lower after laparoscopic repair (281 of 1143, or 24.6%
vs 331 of 1106 (or 29.9%)(p=0.002) (0.73[0.61, 0.89]).
Summarizing all the analyzed RCT, they found an
incidence of four in 3503 (0.1%) intraoperative bowel
lesions in laparoscopic repairs (TAPP/TEP) vs an
incidence in open mesh repairs of two in 3538
(0.06%). There was no significant differences
between the two groups (p=0.4) (2.01 [0.40, 9.99]).
The incidence of urinary bladder lesions in
laparoscopic repairs was four of 3503 (0.01%) vs
zero in 3538 after open mesh repairs; this difference
reached statistical significances (p=0.05) (7.31 [1.03,
51.95]). All of the bladder lesions were reported in
trials comparing laparoscopic techniques with open
non-lichestein mesh repairs.
One study reported bleeding from a retroperitoneal
blood vessel (A iliaca communis) during a TAPP
operation; another reported two cases of bleeding
that required reoperation. Thus, the overall incidence
of vessel lesions in laparoscopic repairs was there in
3503 (0.09%). There were no reported cases of
major vascular demage during open operations. No
statistical differences between laparoscopic and
open mesh repair was found for the incidence of
major vascular lesions (p=0.08) (7.37 [0.77, 70.89]).
Wound infection- a comparison of wound infection
rates showed that the incidence was significantly
lower after laparoscopic techniques (TAPP/TEP) than
after with the lichestein operation (23 of 2250[ 10.%]
vs 62 of 2300 [2.7%] (p=0.00003) (0.39[0.26,0.61]).
Hematoma- The incidence of inguinal hematomas is
significantly lower for the laparoscopic techniques
(TAPP/TEP) than with the lichestein repair (165 of
1261 [13.1%] vs 209 of 1306 [16.0 %] (p=0.005) (0.69
[0.54, 0.90]).
Seroma- Only some of the analyzed studies defined
and evaluated seroma as a complication [26,
107,51,11,44,75,9,56,20,13,104,52,14,112,107,23,113,
58,29,74]. These studies that did evaluate this
parameter found a significantly higher incidence of
seroma after laparoscopic procedures in comparison
to the lichestein repair (194 of 1590 [12.2%] vs 144 of
1620 [8.9%]) (p=0.003) (1.42 [1.13, 1.79]).
Urinary retention- The incidence of post operative
urinary retention was reported by only a limited
number of studies [72,106,23]. Meta analysis of
these study results showed no significant differences
between laparoscopic and lichestein repair (59 of
1164 [3.5%] vs 46 of 1697 [2.7%] (p=0.16)(1.32[0.89,
1.94]).
Time to return to work- The mean time to return to
work or normal activities in the analysis of trials
comparing laparoscopic techniques with lichestein
repair was 14.8 days (ranges 5-46) after
laparoscopic operation vs 21.4 days (ranges 7-43)
after lichestein repair (p<0.00001) (-1.35 [-1.72,-
0.97]).
Inguinal paresthesia- The result of the studies that
included information about inguinal or scrotal
paresthesia [25,67,74,86,90,98,99,111] indicates that
the laparoscopic operations result in a cumulative
incidences of 76 of 1948 (3.9%) cases vs 159 of 1976
(8.0%) after lichestein repair (p<0.00001)(0.46[0.35,
0.61]).
Long term follow up- When all the studies are
summarized a mean follow up time of 27.9 months
with a follow up rate of 94.9% is found. only
a very few of the studies provided data for a follow
up period extending over several years.
Table 7. Visceral lesions in randomized controlled
trials comparing laparoscopic and open mesh repair
techniques.
Lesion Authors[ref.no.] Trial Comparison
Incidence
Bowe Anders Lund 2003 TEP vs LI 1/81 vs 1/87
l son et
injury al [2]
Mahon Norwich TAPP vs 2/59 vs 0/60
et al 2003 LI
[67]
MRC Mrc EN vs 0/462 vs
[74] multicentre OM 1/453
1999
TEP vs LI
 Neuma Veterans 1/989 vs
yer 2004 0/994
[78]
Urinar MRC MRC EN vs 1/462 vs
y [74] multicenter OM 0/453
bladd 1999
er
lesion
Johans SCUR 1997 TAPP vs 2/207 vs
on et al OPP 0/199
[49]
Aitola Tampere TAPP vs 1/24 vs 0/25
et al [1] 1998 OPP
Vasc MRC MRC EN vs 1/462 vs
ular [74] multicenter OM 0/453
injury 1999
Neuma Veterans TEP vs LI 2/989 vs
yer 2004 0/994
[78]

Chronic pain- in the long term follw up, the incidence

of inguinal or scrotal chronic pain syndromes was
documented in only a relative few of the
publications(fig.4)[1,6,10,22,25,32,41,45,46,
49,50,60,66,67,68,86,91, 101,105,114]. In studies
comparing laparoscopic techniques to the lichestein
repair a significantly lower incidence of chronic pain
was documented after laparoscopic operation (125
of 1650 [7.6%] vs 208 of 1642 [12.7%]) (p<0.00001)
(0.56[0.44, 0.70]).
Testicular problems- There was no significant
difference between laparoscopic and open mesh
repair in the incidence of postoperative testicular
problems. Overall incidence of 19 in 3170 (0.06%)
after laparoscopic procedures and 26 of 3177
(0.08%) after open mesh repair (p=0.7)(0.71[0.39,
1.28]).
Hernia recurrence- They found a significantly higher
rate after laparoscopic techniques than after
lichestein repair (112 of 2042 [5.5%] vs 56 of 2058
[2.7%]) (p=0.00001) (2.00[1.46, 2.74]). This result
was strongly influenced by the veterans Affairs
multicenter trial [17]; A when these data are
excluded, there is no statistical significant difference
between laparoscopic and lichestein repair in the
recurrence rate.
Currently, the most extensive and hghest quality
meta analysis comparing laparoscopic and open
operation techniques for the repair of inguinal hernia
can be found in the work of the European hernia
trialists collaboration[57,58]. However the current
version [57] contains only studies published up to
1999. In the succeeding 8 years, additional
randomized studies were published; moreover,
some of the studies now provide long-term results
that cover a follow up period of >5 years.
Morbidity rates in the individual trials depends on the
definition of “complication” and the sensitivity of
detection;indeed, seem to be more frequent with
laparoscopic techniques than with open mesh repair.
In most cases, the reported complications in
laparoscopic procedures were dignosed immediately
and managed adequetly without any need to change
the initially planned repair technique. Most of the
visceral lesions in the laparoscopic procedures were
incurred when the TAPP routes was used; however
when the TEP technique is applied, intraabdominal or
retroperitoneal injuries may also occur [17,81,87].
Proven expertise in laparoscopic surgery and
experience with intraabdominal or suprapubic
operations with consequent adhesions seems to be
the most important risk factors for visceral or
vascular lesionas [32,101].
The incidence of hematoma appears to be higher
after open repair than after laparoscopic procedures.
A factor that cannot be excluded, however is that
clinical examination after laparoscopic operation
simply does not detect prepertioneal hematoma to
the same extent as subcutaneous hematoma after
open repair. A standardized postoperative
sonographic examination, with measurement of the
fluid collection, should be carried out to evaluate this
parameter objectively.
Prepertioneal prepration appears to be a risk factor
for the development of postoperative seroma around
the mesh prosthesis or the former hernia site.
Seromas that aries after laparoscopic inguinal hernia
repair usually have no pathologic value and
disappears spontaneously.
A visible inguinal swelling, however may worry
patients and general practitioners after hospital
discharge; thus, it is advisible to offer information on
the benign nature of this phenomenon to the patient
preoperatively. Percutaneous aspiration is seldom
necessary [12]. The use of light weight meshes may
reduces the inflammatory tissue reation and inhibit
subsequent seroma formation[102].

In a large review, Jensen et al [50] postulated a

higher incidence of postoperative urinary retention
when hernias are repaired under general (3.0%) or
regional anesthesia (2.4%) rather than local
anesthesia (0.4%). In this meta analysis, the
incidence of postoperative urinary retention after
laparoscopic procedure was not significantly
different from that after the lichestein repair.
However, a comparison of laparoscopic procedures
with non lichestein open mesh repair revealed a
tendency (which nearly reached statistical
significance at (p=0.06) to be higher after
laparoscopic hernia repair, which was performed
exclusively under general anesthesia.)
Postoperative return to normal physical activities
and work is influenced by a large number of factors.
The trials analyzed here recorded a wide variety of
time periods for return to normal activities and work,
as would be expected in different health care
settings and based on the diverse insurance status
of the patients. However the trials were highly
homogenous in documenting a significantly shorter
convalescence period after laparoscopic
procedures; this repaid recovery might be
associated with a reduction in wound pain.

Intraoperative nerve injury leads to postoperative

paresthesia or neuralgia, which is relatively frequent
after open hernia repair. Some surgeons may dissect
the ilioinguinal or genitofemoral nerve to prevent
postoperative pain syndromes.with the laparoscopic
approach these nerves can be circumvented safely,
avoiding dissection of the “triangle of pain”.
The trials homogenously showed that the incidence
of postoperative paresthesia or neuralgia was lower
after laparoscopic hernia repair. The lower incidence
of nerve injury associated with the laparoscopic
approach was confirmed by the reduced incidence
of chronic pain syndromes was documented after
laparoscopic hernia repair[99]. The risk factors for
postherniorrhaphy chronic pain syndromes may be
the preoperative presence of inguinal pain and the
intraoperative production of lesions of the ilioinguinal
nerve.
The recurrence rate is dependent on technical details
and therefor on the education and experience of the
surgeon. Similar rules apply for open and
laparoscopic mesh implantation; however, the
laparoscopic approach seems to be more complex.
In various analysis [84,85], the following causes of
recurrence after laparoscopic hernia repair were
identified: inadequate dissection of the prepertioneal
space, slit in the mesh, inadequate prosthesis size,
inadequate prosthesis overlap of the hernia defects,
improper fixation, folding or twisting of the
prosthesis, missed hernias, and lifting of the mesh
secondary to hematoma formation. When a
technical error is defined as the cause of a
recurrence after laparoscopic repair, the recurrence
seems to appear early.

Liem et al.[65] reported that15 of 21 recurrence

(71%) after TEP appeared within the 1st postoperative
year, whereas only 16 of 43 recurrence (37%)
occurred after open suture repair without mesh
implantation. Various randomized studies [78] and
error analysis of larger series [10,32,106] were able
to show that with adequate surgical technique and
training the recurrence rate after laparoscopic
operation can be reduced significantly.
In large series that included the learning curve,
recurrence rates of 1% have been reported after the
laparoscopic repair of primary and recurrent hernia
[10,106]. The laparoscopic approach to recurrent
hernias after previous open repair seems to have
clear advantagesover the open approach[107]. The
reduced indirect costs of treatment after
laparoscopic repair may compensate for the higher
direct costs making the laparoscopic approach a
cost-effective option for the management if inguinal
hernias [72,108], especially recurrent and bilateral
hernias.
Based on the literature, TEP procedures were
performed exclusively by Ramshaw et al.[91] Fazzio
[30], Pawanindra lal et al. [56],Schneinder et al.
[102], feliu et al. [33], and winslow et al. [103].
Schwab et al.[104] performed 1561 (82%) TEP, 324
(17%) TAPP, and 18 (0.9%) intraperitoneal only mesh
(IPOM) procedures. Heikkinen et al.[44] split his
laparoscopic groups, performing 22 TEP and 40
TAPP procedures. Schmedt et al. [100] and Bell and
price performed all TAPP repairs.
All open repairs were performed in the manner of
lichestein except Feliu who did prepertioneal open
repairs. Hiekkinen et al.[44] reported an 8%
recurrence rate for the laparoscopic repair. Early in
their series the mesh size was 6.10cm and in later
repairs the mesh was 10.14 cm. All the recurrence
 were seen in the early groups. Schwab et
al.[104],who had a higher major complication rate
with the laparoscopic repair, admitted that the
complications occurred early in their experience.
Syudy No.of Recurre Minor Major
patient nce compl. compl.
s
Schwab 1388 11 83 (6.0%) 18(1.3%)
[104] 2002 (0.6%)
(L)
Fazzio [30] 408 1 (0.2%) 3 (0.74%) 0
2002 (L)
Schmedt 5524 55 Total 202
[100] 2002 (1.8%) (3.7%)
(L)
Ramshaw 337 1 (0.3%) 22 (6.5%) 0
[91] 2003 (L)
Bell [7] 2003 186 1 10 (5.4%) 0
(L) (0.53%)
Pawanindra 25 0 16 (64.0%) 0
[56] 2003 (O)
Pawanindra 25 0 3 (12%) 0
[56] 2003 (L)
Schneider 28 1 (3.6%) 4 (14.3%) 0
[102] 2003
(O)
Schneider 28 1 (3.6%) 5 (17.9%) 0
[102] 2003
(L)
Winslow 198 0 104 (52.5%) 0
[103] 2004
(O)
Winslow 147 3 (2.0%) 49 (33.3%) 0
[103] 2004
(L)
Feliu [33] 110 2 (1.8%) 29 (23.9%) 0
2004 (L)
Feliu [33] 78 1 (1.3%) 12 (13.9%) 1 (1.3%)
2004 (O)
Heikkinen 59 2 (3.4%) 3 (5.0%) 1 (1.7%)
[44] 2004 (O)
Heikknen 62 5(8.0%) 0 1 (1.6%)
[44] 2004 (L)
** O: open repair ; L: laparoscopic repair
These recent publications show similar results with
open and laparoscopic approaches regardind
recurrence and complications.
Cost effectiveness is a major area of research
recently. Cost effectiveness analysis examines a
different dimension than do the traditional surgical
outcomes measures of morbidity and mortality, and
in the case of hernia repair, the rate of recurrence.
Cost effectiveness analysis highlights the importance
of patient-reported outcomes and costs when
evaluating surgical procedures. That the traditional
medical outcomes and the patientreported and cost
measures are not completely congruent is consistent
with the finding of others; a recent metaanalysis of
37 randomized clinical trials of hernia repair [17]
found that although LAP (specifically, total
extraperitoneal) was associated with notably more
recurrence than open, the rate did not greatly
influence cost effictiveness; patients disutility
associated with long term pain and numbness
considerably influenced cost effictiveness.

Veterans Affairs Randomized controlled trial[105]

concluded LAP is not cost effective compared with
OPEN when considering all hernia procedures. Costs
for the operation were higher for LAP compared with
OPEN and costs for health care use through 2
postoperative years were similar. QALYs were also
similar. For unilateral primary and unilateral recurrent
hernias,however, LAP was moderately more likely to
be cost effective compared with OPEN, because
LAP is not cost effective for all patients, surgeons
and patients should carefully consider the patient-
specific benefits and risks of open vs LAP.
Consideration of patient centered outcomes and
cost outcomes rather than traditional morbidity and
mortility measures alone is important. The traditional
measures of morbidity and mortality do not
important dimensions of quality of life.
A recent prospective study [109] revealed 22%
occurrence of bilateral inguinal defects in the
patients who are dignosed with pure inguinal hernia
before surgery, with higher incidence for those with
left inhuinal hernia. It appears that routine
contralateral groin exploration and evaluation during
TEP is valuable. Patients with occult bilateral hernias
are benefit from bilateral TEP.

Learning curve
The rapid introduction of laparoscopic
surgery has confronted many surgeons with a
completely new surgical skill to learn. A learning
curve exists before one is able to optimally
perform laparoscopic hernia repairs.
The importance of learning curve has been
stressed by Bittner in the analysis of 8050
cases of TAPP repair.
Effect of learning curve in laparoscopic hernia
repair, comparing early and subsequent cases
in 8050 repairs(TAPP).
First 600 Subsequent
cases cases
Duration of 50 mins 42
surgery mins
Morbidity 9.3% 2.6%
Reoperation 1.3% 0.4%
Recurrence 4.8% 0.4%
rate
The morbidity and recurrence rates of surgeons
with an experience of more than 300 surgeries
were considerably lower than surgeons with
experience of less than 300 cases.
Learning curve in laparoscopic hernia repair
Morbidity and recurrence in relation to
surgeon’s experience

Experience of Experience of
<300 surgeries <300 surgeries
No. of hernia 900 5240
repairs
Opening 50(20-155) 40(15-265)
time
Morbidity 7.1 2.4
rate (%)
Reoperation 1.2 0.4
rate (%)
Recurrence 3.6 0.4
rate (%)

Current status of laparoscopic hernia repairs

In conclusion, the above meta-analysis shows that
the laparoscopic techniques do have advantages
compared over open mesh repair in terms of local
complications and pain associated parameters
which also effects the long term follow up. Most of
the trial results were obtain with the less
standardized laparoscopic techniques as performed
by surgeons who had limited experience with
laparoscopic hernia repair, having in most cases
operated only on unilateral primary inguinal hernias.
Although it is difficult to know the exact percentages
of hernia repairs being performed, Rutkow estimated
that in 2003 in the united states, of approximately
800,000 groin hernia repairs, 14% were performed
laparoscopically: 37% were lichestein repairs 34 %
were plug repairs, 8% were other mesh repairs, and
only 7% were pure tissue repairs[75].
Because of the difficulty of laparoscopic repairs, and
the relative ease of the open mesh repairs, the
laparoscopic approach is not likely to became the
dominant groin hernia repair. Until there is better
training for laparoscopic procedures during surgery
residencies and fellowship this technique is not likely
to increase in popularity for some time.
Results
OBSERVATIONS
This is a prospective comparative type of study
between Laparoscopic TEP repair and Open
Lichtenstein repair of Inguinal hernia conducted
in S.M.S. Medical College.
Total 100 patients were included in this study;50
each in the two groups,the Laparoscopic TEP
group and Open Lichtenstein group.
[I] Demographic profile of the patients - 99
patients were Male and 1 Female.
The patients were in the age group of 15-76
years.Mean age in the Laparoscopic group was
39.54 years and the Open Lichtenstein group
was 42.78 years.There was no significant
difference in the mean age in the two groups
on statistical analysis so they are compairable.
Table1.Patients Age Profile(Mean,S.D.&Range)
Groups
Age LICHTESTEIN Total
TEP
MESH REPAIR
<20 4 3 7
21—30 15 6 21
31—40 10 10 20
41—50 8 6 14
51—60 6 6 12
61—70 5 11 16
>70 2 8 10
Total 50 50 100
 Age wise distribution
16
sesac

14 15
12
fo

10 11 Groups TEP
oN

10 10 Groups
8
8 8 LICHTESTEIN
6 MESH REPAIR
6 6 6 6
4 5
4
2 3
2
0
<20 21--30 31--40 41--50 51--60 61--70 >70
Age

Mean AGE
44.00

43.00
naeM

42.00 42.78
41.00

40.00

39.00 39.54
38.00

37.00
TEP LICHTESTEIN MESH REPAIR

Tab 2.

Groups No of cases Mean AGE ± SD p value

TEP 50 39.54 15.989

0.451 [ Not
LICHTESTEIN significant
MESH 50 42.78 17.258 difference]
REPAIR
[p >0.05(0.451)-No significant difference of
age in the two groups]Student ‘t’ test
Tab 3. Sex wise distribution of cases

Groups
Sex LICHTESTEIN Total
TEP
MESH REPAIR
Male 49 50 99
Female
1 0 1

Total 50 50 100
Sex wise distribution
60
sesac

50
49 50 Groups TEP
fo

40 Groups
oN

LICHTESTEIN MESH
30
REPAIR
20

10

0
Male 1 Female
0

In our study 99% are male patients and only 1%

are female patients.
Table 4.Side of Hernia operated in each group.
Groups
Side of Hernia Total
LICHTESTEIN
TEP
MESH REPAIR
Right 26 23 49

Left 8 13 21
 Bilateral 16 14 30

Total 50 50 100

Majority of the patients had right sided inginal

hernia 49%,52% in TEP group and 46% in the
Open Lichtenstein group.Overall Right side
more common than B/L and lowest is left sided
in this study.In TEP group 32% bilateral(B/L)
and 16% left sided.In Open 28% B/L and 26%
left sided.
Side of Hernia
30
sesac

25
26
fo

20 23 TEP
oN

LICHTESTEIN
15 MESH REPAIR
16
10 13 14

5 8
0
Right Left Bilateral

Table 5. Type of defect found intraoperatively-

Groups
Type of
Total
Hernia LICHTESTEIN
TEP
MESH REPAIR
Direct 19 21 40

Indirect 31 29 60
 Total 50 50 100

Type of Hernia
35
sesac

30
31
25 29
fo

TEP
oN

20 LICHTESTEIN
21 MESH REPAIR
15 19
10
5
0
Direct Indirect

[II] Operative Time- The operative time was

noted in each case from the time of first
incision to the last skin stitch applied. The mean
operative time of laparoscopic TEP repair was
87.90 min with S.D of+-26.23.The mean
operative time of Open Lichtenstein repair
was55.54 min with S.D of +-16.37.
Table 6. Operative Time(Mean,Std.deviation) in
the two groups.
Mean
Groups OPERATIVE ± Std. Deviation p value
TIME [ min]

TEP 87.90 26.23

LICHTESTEIN
55.54 16.37 <0.001
MESH REPAIR

Mean OPERATIVE TIME [ min] of Groups

100.00
90.00
80.00 87.90
naeM

70.00
60.00
50.00
55.54
40.00
30.00
20.00
10.00
0.00
TEP LICHTESTEIN MESH REPAIR

[p<0.001 Laparoscopic TEP procedure is

significantly lengthy than open
Lichtenstein]Student`t` test
III . Postoperative Pain-
Table 7. Visual Analogue Scale(VAS) Pain
Score.Mean(+-S.D) at 24 hrs. postoperatively
VAS SCORE
AT 24 HR
POST No of cases Mean ± SD p value
OPERATIVE
PERIOD

TEP 50 2.96 .638

 <0.001 [ this
was
LICHTESTEIN statistically
MESH 50 3.60 .969 significant-
REPAIR higher in
LICHTESTEIN
MESH group]

VAS SCORE AT 24 HR POST OPERATIVE PERIOD

4.00
3.50
naeM

3.00 3.60
2.50 2.96
2.00
1.50
1.00
0.50
0.00
TEP LICHTESTEIN MESH REPAIR

Table 8. Visual Analogue Scale(VAS) Pain

Score.Mean(+-S.D) at 72 hrs. postoperatively
VAS SCORE
AT 72 HR
POST No of cases Mean ± SD p value
OPERATIVE
PERIOD
<0.001 [ this
TEP 50 1.88 .480
was
statistically
LICHTESTEIN significant-
MESH 50 2.30 .614 higher in
REPAIR LICHTESTEIN
MESH group]
 VAS SCORE AT 72 HR POST OPERATIVE PERIOD
2.50

2.00 2.30
naeM

1.88
1.50

1.00

0.50

0.00
TEP LICHTESTEIN MESH REPAIR

Table 9. Visual Analogue Scale(VAS) Pain

Score.Mean(+-S.D) at 1st week postoperatively
VAS SCORE
AT 1st WEEK
No of
POST Mean ± SD p value
cases
OPERATIVE
PERIOD
TEP 50 .44 .577 <0.001 [this
was
statistically
LICHTESTEIN significant
MESH 50 1.06 .978 higher in
REPAIR LICHTESTEIN
MESH group]
 VAS SCORE AT 1 ST WEEK POST OPERATIVE PERIOD
1.20
naeM

1.00
1.06
0.80
0.60
0.40
0.44
0.20
0.00
TEP LICHTESTEIN MESH REPAIR

Table 10. Visual Analogue Scale(VAS) Pain

Score.Mean(+-S.D) at 2nd week postoperatively

VAS SCORE
AT 2nd
WEEK POST No of cases Mean ± SD p value
OPERATIVE
PERIOD

<0.001 [ this
TEP 50 .02 .141 was
statistically
significant -
higher in
LICHTESTEI LICHTESTEI
N MESH 50 .36 .598 N MESH
REPAIR group]
 VAS SCORE AT 2 ND WEEK POST OPERATIVE PERIOD
0.40
0.35
naeM

0.30 0.36
0.25
0.20
0.15
0.10
0.05
0.00
0.02
TEP LICHTESTEIN MESH REPAIR

[p <0.05 - significant difference] Student ‘t’

test
The post operative pain was recorded at 24
hours,72 hours,1st week and 2nd week after
operation by using visual analogue Scale(VAS)
pain scoring system.The mean pain score out
of 10 at 24 hours was 2.96(+-0.638) and 3.60(+
-0.969) in TEP and Lichtenstein groups
respectively.The mean pain Score of TEP and
Lichtenstein repair at 72 hours was 1.88 and
2.30 respectively.
The mean pain score in the TEP group was
significantly less than the Lichtenstein group on
all occasions upto 2nd week. i.e. VAS score at
24 hours,72 hours,1st week and at 2nd week.
There were one case in the Lichtenstein group
where pain was severe,localized,continuous
type and continued beyond 2nd week
postoperatively.They were diagnosed as
Haematoma due to deranged coagulation
profile.These patients required more potent and
longer oral analgesic i.e Tramadol 50 mg TID.
In contrast, there was no one such case of
severe pain in TEP group,which require
potent and longer oral analgesic .
VI . Anaesthesia – All patients in TEP group
were operated under general anesthesia.In
contrast,majority of Lichtenstein group 45 were
operated under Spinal block, 4 under Local
anesthesia and 1 under general anaesthesia.
Table 11. Type of Anaesthesia used-
Groups
TYPE OF
LICHTESTEIN Total
ANAESTHESIA TEP
MESH REPAIR
GA 50 1 51
Local 0 4 4
Spinal 0 45 45

Total 50 50 100
 sesac
TYPE OF ANAESTHESIA
60
50 Groups
40 50 TEP
fo

Groups
oN

30
33 LICHTESTEI
20 N MESH
10 REPAIR
12
0
3
GA1 0
local 0 1
Local 0
spinal 0
Spinal

V . Intraoperative complications-
Table 12. Intraoperative Vascular Injury-

Groups
VASCULAR
Total
INJURY LICHTESTEIN
TEP
MESH REPAIR
No 50 49 99

Ilio-inguinal 0 1 1

Total 50 50 100
VASSCULAR INJURY
sesac

60
50 Groups
40 50 49 TEP
fo

Groups
oN

30
20 LICHTESTEI
N MESH
10
REPAIR
0
No 0 1
Ili-inginal
VASSCULAR INJURY
Table 13. Intraoperative Nerve Injury-
Groups
NERVE INJURY Total
LICHTESTEIN
TEP
MESH REPAIR

Yes 0 0 0

No 50 50 100
NERVE INJURY
sesac

60
50 Groups
40 50.00 50.00 TEP
fo

Groups
oN

30
20 LICHTESTEI
N MESH
10 REPAIR
0
0.00Yes0.00 No
NERVE INJURY

Table 14. Intraoperative Bowel Or Bladder Injury

-
BOWL OR Groups
BLADDER INJURY
Total
INTRA OPERATIVE LICHTESTEIN
COMPLICATIONS TEP
MESH REPAIR

Yes 0 0 0

No 50 50 100
 BOWL OR BLADDER INJURY INTRA OPERATIVE
COMPLICATIONS
60
sesac

50
50.00 50.00
40
fo

Groups TEP
oN

Groups
30 LICHTESTEIN
MESH REPAIR
20

10

0
0.00 Yes 0.00 No
BOWL OR BLADDER INJURY INTRA OPERATIVE COMPLICATIONS

In the laparoscopic TEP group,there were no

major complications like bladder injury,bowel
injury or major vascular injury as described in
the literature.
One patient developed subcutaneous
emphysema over anterior abdominal wall
probably due to port displacement during
surgery which is resolved uneventfully by
conservative means. Three patient
developed pneumoperitoneum probably due to
tearing of peritoneum during formation of
space preperitoneally near anterior superior
iliac spine.Pneumoperitoneum treated by
introducing verre`s needle in right subcostal
region.
There were no conversion from TEP to open
Lichtenstein repair.
VI . Post operative Complications –
Table 15. Postoperative complications- There
were 5 cases(10%) of nausea in each group.7
cases(14%) of seroma formation in the open
Lichtenstein group detected on 5 postoperative
day.There was no one case in both groups
which has incision site infection.
complica TEP Lichtens
tions group(n tein
=50) group(n
=50)
Nausea 5 5
Seroma 0 7
Incision 0 6
site
induratio
n
Numbne 0 1
ss
Hemato 0 1
ma
Seconda 0 1
ry
Hydrocel
e
VII. Postoperative Urinary Retention –
In Lichtenstein group 5 case(10%) has
postoperative urinary retention which is due to
pain at the operating site,in which 3 cases
required catheterization.Catheter removed on
48 hrs after.While in TEP group no one
complained of urinary retention which may be
due to perioperative catheterization and old
aged patients had removal of catheter on
postoperative day 2.
Table-16

Groups
URINARY
Total
RETENTION LICHTESTEIN
TEP
MESH REPAIR

Yes 0 5 5

No 50 45 95

Total 50 50 100
 URINARY RETENTION
60
sesac

50 Groups
50 TEP
40 45
fo

Groups
oN

30
LICHTESTEI
20 N MESH
10 REPAIR
0 5
0 Yes No

VIII . Post operative Hospital Stay –In TEP

group,49 cases are discharged on day
2.Patients were given the instructions to decide
their own course of hospital stay.Only one case
discharged on day 3 because of felling
unwellness with vertigo.The mean hospital stay
was 2.02 days.In Open group 29 patients(58%)
were discharged on day 2,eight cases(16%)
were discharged on day1,one case on
day11,two cases on day7.the patients with more
pain and postoperative complications were
willing for stay in hospital for a longer
time.Mean hospital stay was 2.54 days.There
was significant longer hospital stay in Open
Lichtenstein group.
Table- 17
STAY AFTER
SURGERY
No of
POST Mean ± SD p value
cases
OPERATIVE
PERIOD
0.042
TEP 50 2.02 .141 [this was
statistically
significant-
LICHTESTEIN
MESH 50 2.54 1.775 longer stay in
REPAIR LICHTESTEIN
MESH group].
STAY AFTER SURGERY POST OPERATIVE PERIOD
3.00
2.50
naeM

2.54
2.00
2.02
1.50
1.00
0.50
0.00
TEP LICHTESTEIN MESH REPAIR

IX . Duration of Parentral Antibiotic- Table-18

DURATION OF
PARENTERAL
ANTIBIOTIC
No of cases Mean ± SD p value
POST
OPERATIVE
PERIOD
TEP 50 .24 .476 <0.001 [this was
statistically
significant –
LICHTESTEIN
50 1.14 1.591 longer in
MESH REPAIR
LICHTESTEIN
MESH group
 cases]

There is significant difference in antibiotic

intake in between two groups which is required
more for Lichtenstein group.
DURATION OF PARENTERAL ANTIBIOTIC POST
OPERATIVE PERIOD
1.20
1.00 1.14
naeM

0.80
0.60
0.40
0.20
0.24
0.00
TEP LICHTESTEIN MESH
REPAIR

X . Return of Bowel function – Table -19

RETURN OF
BOWEL
FUNCTION
No of cases Mean ± SD p value
POST
OPERATIVE
PERIOD
0.006 [ this
TEP 50 2.12 .328 was
statistically
LICHTESTEIN significant –
MESH 50 2.38 .567 longer in
REPAIR LICHTESTEIN
MESH group]
Return of bowel function was earlier in TEP
group than Open group.Mean for TEP is 2.12
days and in Lichtenstein group is 2.38 days.
 RETURN OF BOWEL FUNCTION POST
OPERATIVE PERIOD
2.45
2.40
2.35
naeM

2.30 2.38
2.25
2.20
2.15
2.10
2.05 2.12
2.00
1.95
TEP LICHTESTEIN MESH
REPAIR

XI . Return to Work –
The patients were instructed to return to work
when they feel after discharge from the
hospital.They were to report the day of joining
work when called for follow up.The mean return
to work for Open group was 17.00 and TEP
group was 11.34 days.
RETURN TO
WORKPOST
No of cases Mean ± SD p value
OPERATIVE
PERIOD
<0.001 [ this
TEP 50 11.34 1.996 was
statistically
significant –
LICHTESTEIN longer in
MESH 50 17.00 3.482 LICHTESTEIN
REPAIR MESH group]
 RETURN TO WORKPOST OPERATIVE PERIOD
18.00
16.00 17.00
naeM

14.00
12.00
10.00 11.34
8.00
6.00
4.00
2.00
0.00
TEP LICHTESTEIN MESH REPAIR

There is significant early return to work in TEP

group.
XII . Recurrence –
RECURRENCE Groups
POST
LICHTESTEIN Total
OPERATIVE TEP
PERIOD MESH REPAIR
Yes 0 0 0
No 50 50 100
Total 50 50 100
 RECURRENCE POST OPERATIVE PERIOD

60

50
sesac

50 50
40
fo

Groups TEP
oN

30 Groups
LICHTESTEIN
MESH REPAIR
20

10

0
0 Yes 0 No
RECURRENCE POST OPERATIVE PERIOD

There is no any recurrence in both groups.

XIII . Re-Admission–
READDMISSION
Groups
REQUIRED
POST Total
OPERATIVE LICHTESTEIN
TEP
PERIOD MESH REPAIR

Yes 0 0 0

No 50 50 100

Total 50 50 100
 RE ADMISSION REQUIRED POST OPERATIVE
PERIOD
sesac

60
50
40
50 50
fo

Groups TEP
oN

30 Groups
LICHTESTEIN
20 MESH REPAIR
10
0
0 Yes 0 No
READDMISSION REQUIRED POST OPERATIVE PERIOD

There is no any readmission in both groups.

DISCUSSION
The present study was carried out on 100
patients admitted in surgical Unit III,Department
of Surgery,Swai Man Singh Medical College
and Hospital,Jaipur,with the clinical diagnosis
of inguinal hernia from January 2014 to January
2016.
The patients were randomized into two groups
on admission to the indoor wards by systemic
random sampling i.e.one into Laparoscopic TEP
group and another into Open Lichtenstein
group.
Demographic data – All the patients in both
groups were male except one female in TEP
group.This was unintentional.The mean age of
patients in the laparoscopic TEP group was
39.54 years and was less than the age in
Lichtenstein group i.e. 42.78 years.The mean
age of patients in both the groups was not
statistically different.The patients were equally
distributed in the age groups 21—30, 31—40,
41—50,51-60,61-70 i.e.about 44% in TEP
group and 47% in Open group with <20 is 4%
and 3% in TEP and Open group. 2% in TEP and
8% in Open group had >70 year age.
In TEP group,26(52%) patients had Right sided
hernia,8(16%) Left sided hernia and 16(32%)
had bilateral hernia.Overall 49% patients had
Right sided hernia.In literature,the prevalence
of hernia is stated to be more in males by ratio
of 7:1.The prevalence of hernia in male is clearly
age dependent and Right sided groin hernia are
more common than the left.
Nyhus classification of hernia were used to
type the hernia based on intraoperative
findings.Majority of patients in the TEP(48%)
and Lichtenstein group(51%) were either
medium sized indirect(Nyhus type II) or
direct(Nyhus type III) hernia.
In addition,those patients undergoing
Laparoscopic TEP repair were classified
according to the SGRH classification of TEP
repair.Most patients were SGRH grade II(54%)
or Grade III(46%).SGRH grade V was excluded
from the study.
Operative time – The mean operative time of
TEP repair was 87.90minutes(range ).This was
significantly longer than the operative time for
Open Lichtenstein repair(Mean,Range).The
operative time improved with the learning curve
of the surgeon and assistant which holds
laparoscope. The mean operative time of TEP
repair in our series is slightly longer than all
other published series[55].This could be
explained by the fact that we still need little
more expertization and due to large indirect sac
which took longer time to dissect and due to
unexpertiztion of camera holding assistant
.Expertization of the assistant is also necessary
because of poor visualization leads to
intraoperative complications,poor placement of
mesh will leads to more operative time.
Mean operative time in series by Anderson et
al[2] was 81(+-27) min and Suter et al[104] 82
min.Other series had lesser mean operating
times.Our mean operative time for Lichtenstein
repair i.e.55.54 min was slightly more than
Wright et al[112] (45 min) and nearer to
Heikkinen et al[44](53 min) and Lal et al[56] (54
min).
Anaesthesia – All patients in TEP group were
operated under general anaesthesia as it is the
safest and most comfortable for the patient and
for the anaesthetist as well.There were no
anaesthtic complications in the patients but
longer mean operative times related to longer
anaesthesia times,more doses of drugs,more
costs and probably delayed recovery from
anaesthesia;all of which are detrimental to the
patient.
Lichtenstein repair was mostly done under
spinal block with its inherent complications due
to inconvenience,lesser time needed and need
of anaesthesia for a short time.
Intraoperative Complications-All complications
were recorded during both operations.
Incidence of vessel injuries in a meta analysis
of randomized controlled trials of TEP vs
Lichtenstein was reported at 0.09%.Liem et al
reported a 0.25% epigastric artery injury and
one case of vas deferens injury.
No extra port(fourth) was introduced in any
laparoscopic case for either dissection of the
indirect sac from the cord structures or the
correct placement of the prolene mesh.
One case in TEP group developed mild Surgical
emphysema intraoperatively which is limited
upto the abdominal wall,is resolved on day first
uneventfully on conservative treatment.The
cause of surgical emphysema was frequent
dislodgement of the trocars from the abdominal
wall causing CO2 to dissect in the
subcutaneous plane.
Three cases in TEP group developed mild
pneumoperitonium due to inadvertent opening
of peritoneum at umbilical port and during
formation of preperitoneal space laterally near
the anterior superior iliac spine.It is treated
intraoperatively by the use of veress
needle/wide bore needle.
There were no conversions of Laparoscopic
TEP repair to open Lichenstein
repair(0%),which is equal or lower than any
published series because of the experienced
surgeon.Lal et al[56] and Lau et al [58]
reported conversion rate at 0%.The conversion
rate of laparoscopic to an open technique
varies from 0 to 1.7% in most series.The
conversion is most frequently performed for the
management of
complications(haemorrhage,digestive tract
injuries,etc.) and occasionally due to technical
problems related to faulty surgical equipments
(Liem et al)[64].
There were no Major vessels and bladder or
bowel injuries in laparoscopic TEP group as
described in various reports,due to careful
meticulous technique of initial port
insertion,preoperative routine urinary
catheterization of all patients and secondary
port insertion under vision.
Bladder injuries were reported Ramshaw et al
[91](0.6%) and a meta analysis reported
incidence of bladder injuries at 0.1% and for
bowel injuries at 0.1% for TEP repairs[78].
Overall,in TEP group no major intraoperative
complications occurred.
Mesh and Fixation- A big size prolene mesh
12*15cm was applied in TEP group to cover all
potential hernia sites and prevent recurrence.It
gives coverage of the orifice of Fruchard and
was simpler to handle and lay down in the
preperitoneal space so better than 15*15 cm
sized mesh .Vipro mesh easy to handle but
much more expensive ;therefore not used
frequently.Lal et al [56]reported that a 0%
recurrence rate was partly due to large (13*15
cm)mesh used in their series.
Endotack tacking device was used in most of
cases but in some (4)cases it is not used
because of better placement of mesh and there
is no such need of tacker for better placement
of mesh and results were same and no other
complications occurred such as recurrence and
other types of hernia on short term
followup.There was obvious advantages in
ease of unrolling of the mesh after fixation.
Lal et al in their series of 25 cases used 5 mm
Tacker device in all cases to fix the mess with
0% recurrence.Lau et al in a case control study
of selective non stapling of mesh concluded
that selective non-stapling of the mesh did not
confer short term benefits,such as reduced
postoperative pain and morbidity,compaired
with those who had routine stapling of the
mesh during TEP.For patients with a hernia
defect measuring less than 4 cm,TEP can be
performed without stapling the mesh.The
selective non-stapling streategy also helps to
reduce the cost of the operation and the
potential for nerve entrapment.
Postoperative Pain and Analgesia requirement-
Postoperative Pain was recorded using Visual
Analogue Scale(VAS) pain scoring systems.The
mean pain score were significantly low in TEP
group as compared to Lichtenstein group in all
readings upto 2 weeks postoperatively.This is
consistent with the findings of other
randomized studies.Lal et al[56] had significant
difference in pain scores after 12 and 24 hours
but not thereafter,which was similar to results
of Liem et al[63] and Champault et al[16].
Postoperative Complications- All complications in
both groups were noted and evaluated.In the
TEP group,seroma formation in the
inguinoscrotal region was nill.This was probably
related to dissection of the space in avasular
plane and delicate handling of the cord
structures and separation of peritoneum,no
extensive dissection and less intraoperative
bleeding/oozing.In Open group seroma eas
present in 7 (14%)cases.This was probably due
to extensive dissection of the space,rough
heandling of cord and intraoperative ozzing.
The patients presented with painless irreducible
swelling in scrotum or inguinal
region,diagnosed clinically.Patients were
anxious because of swelling.they were
reassured and given anti-inflammatory
medication for 5-7 days.All resolved
conservatively at various time periods.Lal et
al[56] reported 12% incidence of seroma and
advocated compression dressing over hernia
site with dyanaplast to reduce seroma
formation.The seroma formation in our study
was higher in comparison to Kald et al[51](2%),
Liem et al[63](1%) and Cohen et al(6%).
Incision site induration present in 6 cases which
has similar reasons.Only one case of each
complication such as numbness,haematoma
and secondary hydrocele.
Postoperative numbness/paresthesia was seen
in no one cases in TEP group but in one(2%)
case of Lichtenstein group .Lal et al[56]
reported 8% incidence of neuralgia in TEP
group and Tamme et al 1.1%.This is reported in
various studies to be a cause of long term
morbidity and lower quality of life in open
repairs.[55]
Hematoma presented as a firmer swelling
which took longer to resolve.It occurred in one
case in the inguinal region in Open group.All
resolved conservatively.Lal et al[56] reported
no incidence of haematoma formation in TEP
and 8% in Lichtenstein group.Liem et al[63]
reported 1.8% hematoma in TEP group.
Wound infection was prevented by routine
antibiotic prophylaxis in every case on morning
of surgery but still wound infection is a major
worry in open repairs due to large incision in
inguinal region & using prosthetic material.Lal
et al reported 4% incidence of minor wound
infection in both the groups while Liem et al
reported 4% incidence of wound infection in
TEP repair and 6(1.5%)wound abscess,2
requiring hospitalization in open group.
Pneumoscrotum was reported as a
complication of TEP repair in the study by Lal et
al[56] at 16% incidence which resolved within 3
hours of surgery.we did not encounter or
specifically look for this benign minor
complication.
Duration of hospital stay-Postoperative hospital
stay was significantly low in TEP group.Lal et
al[56],Khoury et al[52] and andersson et al[2]
shows no significant difference in hospital stay
but other studies showed significantly lesser
hospital stay in TEP repair cases.These results
may be explained by the fact that patients
catheter was removed on the same day after 3
-4 hour or next day with less pain,early
mobilization and early recovery and no major
intraoperative and postoperative
complications.Lal et al[56] reported that TEP
group were electively kept under observation to
watch for complications and so,the study did
not show any difference in hospital stay
between two groups.
Duration to Return to work- Mean duration of
return to work was longer in Lichtenstein
group(17 days) than TEP group(11.34
days).Which is significantly lower in TEP
group.These can be explained by that less
intraoperative and postoperative
complications,early recovery and most of are
not government employ.Patients want early
mobilization and early return to work without
any complication and pain because of many
responsibilities.Which is supported by Hekkinen
et al[44](12 vs 17 days) and Liem et al[53](14 vs
21 days).
Postoperative Antibiotics - Postoperative
parentral antibiotics requirement in TEP (mean
POD 0.24)group is significantly lower than
Open (mean POD 1.14)group.In TEP group it is
required only on day 0 and 1 but it is more for
Open group.Reasion for that is due to longer
hospital stay and postoperative seroma and
hematoma formation.It is given for prevention
of infection in these complications.
Patient Satisfaction – Most patients were
satisfied about their surgery in TEP group but
not all in Open group because of complications
and longer hospital stay.Lal et al[56] reported
that 80% patiets were highly satisfied with the
surgery and 100% with the cosmetic result in
TEP group while the figure was 56% and 28%
respectively in the Lichtenstein group.
Better cosmetic result and low complication
rate is an advantage of using laparoscopic
hernia repair particularly in young patients who
desire better scars.
Recurrence – There was no recurrence in the
short term followup of the patients(mean
followup 3 month).Longer followup will be
necessary to interpret this data.
CONCLUSIONS
 Laparoscopic TEP repair is a significantly
lengthier procedure than open Lichtenstein
 repair especially in the learning phase of
the surgeon.Thereafter,the operative time
decrease but still are more than open
operation.
 Good technique and knowledge about
various potential complications with
experience in TEP repair is essential to
prevent serious complications like bladder
injuries, bowel injuries and major vascular
injuries etc.
 Postoperative pain is significantly less in
TEP repair as compared to Lichtenstein
repair during first 2 weeks of the surgery.
 Postoperative analgesic requirement are
significantly less than Lichtenstein repair.
 Postoperative seroma formation was
significantly less in TEP group.
 Use of large size mesh(6”*6”)reduces
chance of recurrence even in hands of the
learning surgeon.
 Non fixation of mesh is an acceptable
alternative to mesh fixation by
Tacker.Intracorporeal suturing of mesh can
be done as alternative to fixation device.
 Numbness and neuralgia at inguinal region
are less in laparoscopic TEP repair as
compare to Lichtenstein repair.Many
patients in Lichtenstein group continue to
have these symptoms many months after
surgery and are a major cause to long term
morbidity and affects quality of life after
surgery.This is a major limitation of open
hernia surgery including Lichtenstein repair.
 VAS pain scoring system is a fairly good
method of pain charting but sometimes
very difficult to explain to the uneducated
patients.Thus chances of subjective errors
are high.Also this scoring system relies on
the patients pain threshold which is itself
variable.Even all that pain score is
significantly less in TEP.
 Early recurrences can be prevented by
careful separation of peritoneum from the
cord structures and placing large mesh
properly after creating a big enough
space.in our study,no recurrence is noted
on short term follow up for 3 month.
 In our study,contralateral dissection to look
for suspected occult and coincidental
hernia was done and prophyiactic mesh
placement on the opposite site is done.This
practice may avoid development of hernia
on the contralateral side in potential cases
of subclinical hernia in the long term.This
practice proved cost effective and patient
suffering,as it avoids another operation.
 This study showing differences in duration
of hospital stay between the two groups.
Laparoscopic TEP group had only 2 days of
hospital stay because of less postoperative
pain,intraoperative,postoperative
complications and better functional
recovery.
 Most patients in TEP group were satisfied
with their surgery because of less pain,less
wound infection and better cosmetic
results.
 Overall mean duration to return to work was
significantly short in TEP group in
comparison to open Lichtenstein group
because of early recovery,early
 mobilization and less wound complications
postoperatively.
 The cost-effectiveness of Laparoscopic
TEP repair cannot be calculated with
accuracy without long term quality of life
indices like QUALY which are not measured
in this study.Overall,lesser postoperative
pain,early return to work and good quality
of life after TEP repair suggests that
Laparoscopic TEP repair may be cost
effective than Lichtenstein repair.Large
sample size in a randomized study with a
longer follow up will be needed to reach a
final conclusion.
 Laparoscopic repair of inguinal hernia is
more physiological repair because the
mesh prosthesis is used in a tension free
manner at the entry site of the hernia and
the whole myopectineal orifice of fruchard
is covered by a single prosthesis preventing
other groin hernia too in future and it’s the
characteristic feature of laparoscopic
repair.
 Early in the learning phase,surgeon should
select patients with smaller indirect hernias
like bubonocele to prevent difficult
dissection of sac and possible chance of
conversion to open repair.But in our case
surgeon is well expert for doing
laparoscopic TEP.
 Learning curve for TEP repair is considered
to be between 30-50 repairs.Results of
laparoscopic TEP repair in this study
represents a single surgeon`s experience
which is experienced and should be seen in
this light.
 Laparoscopic TEP repair may be done in all
uncomplicated inguinal hernia by an
experienced surgeon for those desiring less
pain,better cosmotic results,less
postoperative complications,less hospital
stay and early return to work.
BIBILIOGRAPHY
1) Aitola P, Airo I Matikenen M (1998) laparoscopic versus
open preperitoneal inguinal hernia repair: a postoperative
randomized trial. Ann Chir Gynaecol 87:22-25
2) Andersson B,Halle`n M,Leveau P,Bergenfelz
A,Westerdahl J(2003)Laparoscopic extra peritoneal
inguinal hernia repair versus open mesh repair : A
prospective randomized controlled trial.Surgery 133:464-
472.
3) Bendravid R 1998. Complications of groin hernia surgery.
Surgical clinics of
North America ;78(6):1089-1103.

4) Bendravid R , Robert E. Codon, Nyhus Lloyd M : Chapter

6, Mastery of surgery
.Lloyd M, Nyhus & Robert J. Baker , Little Brown &
Company, 2ndedition , 1992;
1557-1615.
5) Burke J B & Taylor M 1978 . Clinical & economic effect of
early return to work
after elective inguinal hernia repair . British Journal of
surgery Vol 65: 728-731.

6) Beets GL, Drisken CD, Go PMNYH, Geisler FEA, Baeten

CGMI, Kootstra G (1999) open or laparoscopic
prepertioneal mesh repair for recurrent inguinal hernia.
Surg Endosc 13:323-327
7) Bell RCW, Price JG, laparoscopic inguinal hernia repair
using an anatomically contoured three-dimensionel
mesh.Surg Endosc.2003:17:1784-1788
8) Bessell JR, Baxter P, Riddell P, Watkin S, Maddern GJ
(1996) Arandomized controlled trial of laparoscopic hernia
repair. Surg Endosc 10:495-500.
9) Bilgin B,O”zmen MM,Zu”Ifikaroglu B,Cete
M,Hengirmen S(1997) Totally extra peritoneal(TEP) hernia
repair pre peritoneal open repair(PPOR). Surg Endosc
11:542.
10) Bittner R, Schmedt C-G, Schwarz J, Kraft K, Leibl BJ
(2002) laparoscopic transperitoneal procedure for routine
repair of groin hernia. Br J Surg 89: 1062-1066
11) Bittner R, Sauerland S, Schmedt CG (2005) comparison
of endoscopic technique vs shouldice and other open
nonmesh technique for inguinal hernia repair: a metaanlysis
of randomized controlled trials. Surg Endosec 19: 605-615.
12) Bobrzynski A, Budzynski A, Biesiada Z, Kowalczyk M,
Lubikowski J, Seinko J (2001) Experience the key factor in
successful laparoscopic total extraperitoneal and
transabdominal preperitoneal hernia repair. Hernia 5:80-83
13) Bostanci BE, Tetik C, O” zer S, O”zden A (1998)
posterior approaches in groin hernia repair: open or closed.
Acta Chir Belg 98:241-244.
14) Bringman S, Ramel S, Heikknen TJ, Englund T, westman
B, Anderberg B (2003) Tension free inguinal hernia repair:
TEP versus mesh-plug versus lichestein. A postoperative
randomized controlled trial. Ann surg 237: 142-147.
15) Canon S R et al , 1982 . Early discharge following hernia
repair in unselected
patients. British journal of surgery Vol 69: 112-113.

16) Champault GG, Rizk N, Catheline JM, Turner R,

Bouteliner P (1997) inguinal hernia repair:totally
preperitoneal laparoscopic approach versus stoppa
operation: randomized trial of 100 patients. Surg laparosc
Endosec 7:445-450.
17) Champault G, Benoit J, Lauroy J, Rizk N, Boutelier P
(1994) Hernies de laine de i_adulate: Chirurgie
Laparoscopique vs Ope ration de Shouldice: e tute
randomize e controle e: 181 patients: re’ sultats pre
liminares. Ann Chir 48:1003-1008.
18) Cheek CM, Williams MH, Farndon JR: Truss in the
management of hernia today. Br J. Surg.82:1611-1613, 1995.
19) Chung RS, Rowland DY, meta analysis of randomized
controlled trials of laparoscopic vs conventional inguinal
hernia repairs. Surg.Endosc. 1999;13:689-694
20) Colak T, Akca T, Kanik A, Aydin S (2003) Randomized
clinical trial comparing laparoscopic totally extraperitoneal
approach with open mesh repair in inguinal hernia. Surg
laparosac endoscpercutan Tech 13:191-195.

21) Darzi A, Paraskeva PA, Quershi A, Menzies-Gow

N,Guillou PJ, Monson JR (1994) laparoscopic hernioplasty:
initial experience in 126 patients. J laparoendosac surg 4:
179-183.
22) Davis CJ, Arregui ME. Laparoscopic repair for groin
hernias. Surg.clin. North Am. 2003: 83: 1141-1161
23) Decker D, Lindemann C, Springer W, Low A, Hirner A,
Von Ruecker A (1998) Endoscopic versus conventional
hernia repair from an immunologic point of view. Surg
Endosc 13:335-339.
24) Doctor H G 2001. Re operative surgery for recurrent
hernia. Indian journal of
surgery Vol 63 .no 3: 186- 196

25) Douek M, Smith G, Oshowo A, Stroker DL, Wellwood

JM (2003) postoperative randomized controlled trial of
laparoscopic versus open inguinal hernia mesh repair: five
year follow up. BMJ 326:1012-1013
26) EU hernia trialists collobration (2000) mesh compared
with nonmesh methods of open groin hernia
repair:systematic review of randomized controlled trials. Br
J surg 87: 854-859.
27) Edwards CC 2nd, Bailey RW (2000) laparoscopic hernia
repair: the learning curve.Surg laparoendoscopic percutan
tech 10: 149-153.
28) Eric L Farquharson 1958 .Early ambulation with special
reference to herniorraphy as an out patient procedure.
Lancet, sept 10: 517-519.

29)European Union Hernia Trialists Collaboration(2000)

Laparoscopic compared with open methods of groin
hernia: systematic review of randomized controlled trials. Br
J surg 87:860-867
30) Fazzio FJ. Cost-Effective, reliable laparoscopic hernia
repair: a report of 500 consecutive repairs. Surg. Endosc.
2002:19:931-935
31) Frank Glassow, 1976. Short stay surgery (Shouldice
Technique) for repair of
inguinal hernia . Annals of the royal college of surgeons of
England , Vol 58 :133-
139.

32) Feliu- pala X, Marti-Go mez M, morales conde S,

Ferna’ndez-Sallent E (2001) The impact of the
surgeon’s experience on the results of laparoscopic
hernia repair. Surg Endosc 15: 1467-1470
33) Feliu X, Torres G, Vinas X, et al. preperitoneal repair for
recurrent inguinal hernia: Laparoscopic an open approach.
Hernia 2004: 8:113-116
34) Fitzgibbons RJ jr, Gibbobie-Hurder A, Gibbs JO, Dunlop
DD, Reda DJ, Mccarthy M jr, et al. Watchful waiting vs
repair of inguinal hernia in minimally sysmptometic men: a
randomized clinical trial. JAMA. 2006 jan 18:295 (3):285-92.
35) Fitzgibbons RJ jr, camps J, Cornet DA, et al:
laparoscopic inguinal hernioplasty: Results of a multicenter
trial. Ann surg 221:3-13, 1995.
36) Fleming WR, Elliot TB, Jones RM, Hardy KJ (2001)
Randomized clinical trial comparing totally extraperitoneal
inguinal hernia repair with the shouldice technique. Br J
Surg 88:1183-1188.
37) Ghosh S,Sallam S. Patient satisfaction and
postoperative demands on hospital and
community services after day care surgery. Br J Surg
1994;81:1635-1638.
38) George E Wantz 1984. Complications of inguinal hernia
repair.Surgical clinics of
North America, Vol 64 ,no 2: 287-298.

39) Gilbert A I , M I Graham & W T Voist 1999 .A Bilayer

patch device for inguinal
hernia repair. Hernia Vol 3 : 161-166.

40) Gilbert AI: Sutureless repair of inguinal hernia. Am.J.

Surg.163:331, 1992.
41)Gokalp A, Inal M, Maralcan G, Baskonus I (2003)A
prospective randomized study of Lichtenstein open tension
–free versus laparoscopic totally extraperitoneal
techniques for inguinal hernia repair. Acta Chir Belg 103
:502-506 Hawaii 1994
42)Grant AM, European Union Hernia Trialists Collaboration
(2002) Laparoscopic versus open groin hernia repair: meta
-analysis of randomized trials based on individual patient
data. Hernia 6: 2-10
43) Grant A, laparoscopic compared with open methods of
groin hernia repair: systematic review of randomized
controlled trials. Br. J.Surg. 2000:87:860-867.
44) Heikkinen TJ, Haukipuro K, Koiuvkangas P, Hulkko A
(1998) A prospective randomized outcome and cost
comparison of totally extraperitoneal endoscopic
hernioplasty versus lichestein hernia operation among
employed patients. Surg. Laparosac endosec 8: 338-344.
45)Heikkinen T, Haukipuro K, Leppa’’ la’’ J,
Hulkko A (1998) A cost and outcome comparison
between laparoscopic and Lichtenstein inguinal hernia
repairs: a randomized prospective study .Surg Laparosc
Endosc 18: 518-512
46)Heikkinen TJ, Haukipuro K, Hulkko A (1998) A cost
and outcome comparison between laparoscopic and
Lichtenstein hernia operation in a day -case unit : a
randomized prospective study. Surg Endosc 12:1199-1203
47) Hitendu H Dave et al 1996 .Recurrent inguinal hernias, a
comprehensive study.
Indian journal of surgery , jan-feb: 21-26.

48) Ira M Rutkow 1998 .A selective history of groin hernia

surgery in the early 19th
century .Surgical clinics of North America Vol 78 no 6 : 921-
940.
49) Johansson B, Hallerba B, Glise H, Anesten B,
Smedberg S, Roma NJ (1999) laparoscopic versus open
preperitoneal mesh versus conventional technique for
inguinal hernia repair: a randomized multicenter trial. Ann
surg 230: 225-231
50) Jensen P, Mikkelsen T, Kehlet H (2002)
postherniorrhaphy urinary retention effect of local, regional,
and general anesthesisa: a review. Reg Anesth pain Med
27:612-617
51) Kald A, Anderberg B, Smedh K, Karlsson M (1997)
transperitoneal or totally extraperitoneal approach in
laparoscopic hernia repair: results of491 consecutive
hernioplasty. Surg laparosec Endosac 7:86-89.

52) Khoury N (1998) A randomized prospective controlled

trial of laparoscopic extraperitoneal hernia repair and mesh
-plug hernioplasty: a study of 315 cases. J laparoendosc
Adv Surg Tech 8:367-372.

53) Kings North A and David H. Bennett. Hernia, umbilicus

and abdominal wall
Chapter 62, Bailey and Love’s- Short practice of
surgery,In:Williams NS, Bulstrode
CJK, London A rnold publishers

54)Knook MTT,Weidema WF,Stassen LPS,van Steensel

CJ(1999)Endoscopic total extraperitoneal repair of primary
and recurrent inguinal hernias. Surg Endosc 13:507-511
55) Kuhry E, van veen RE,langeveld HR, steyerberg EW,
Jeekel J, Bonjer HJ. Open oe endoscopic total
extraperitoneal inguinal hernia repair? A systematic review.
Surg Endosec (2007) 21:161-166.
56) Lal P, Kajla Rk, Chander J, Saha R, Ramteke Vk (2003)
randomized controlled study of laparoscopic total
extraperitoneal vs open lichestein inguinal hernia repair.
Surg endosec 17:850-856.
57) Lau H, Patil NG. selective non stapling of mesh
duringunilateral endoscopic totalextraperitoneal inguinal
hernioplasty: a case control study. Arch surg. 2003 Dec;138
(12): 1352-5.
58) Lau H,Patil NG,Yuen WK,Lee F(2002)Management of
peritoneal tear during endoscopic extraperitoneal inguinal
hernioplasty. Surg Endosc 16:1474-1477

59)Leibl BJ,Jager C,Kraft,Schwars J,Ulrich M,Bittner R

(2005) Laparoscopic hernia repair: TAPP or/and
TEP?Langenbecks. Arch Surg 390: 77-82
60) Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R
(2000) Recurrence after endoscopic transperitoneal hernia
repair (TAPP): Causes reparative technique and results of
the reoperation. JAM coll surg 190: 651-655
61)Lichtenstein IL. Herniorrhapy: A Personal experience
with 6321. Am J Surg 1987;
153:553-9.

62)Lichtenstein IL, Shulman AG, Amid PK, et al.The tension

free hernioplasty.Am.J. Surg.1989; 157:188-193.
63) Liem MS, Van der Graaf Y, van Steensel CJ,
Boelhouwer RU, Clevers GJ, Meijer WS, Stassen LP, Vente
JP, Weidema WF, Schrijvers AJ, van vroonhoven TJ (1997)
comparison of conventional anterior surgery and
laparoscopic surgery for inguinal hernia repair. N Engl J
Med 336:1541-1547
64) Liem MSL, Halsema JAM, van der Graaf Y, Schrijvers
AJ, van Croonhoven TJ (1997) cost effectiveness of
extraperitoneal laparoscopic inguinal hernia repair: a
randomized comparison with conventional herniorrhaphy.
Ann Surg 6:668-676.
65) Liem MSL, van duyn EB, van der Graff Y, van
Vroonhoven TJ (2003) Recurrence after conventional
anterior and laparoscopic inguinal hernia repair: a
randomized comparison. Ann Surg 237:136-141.
66) Lowham AS, Filip CJ, Fitzibbons RJ, Stoppa R, Wantz
GE, Felix EL, Crafton WB (1997) mechanism of hernia
recurrence after preperitoneal mesh repair: traditional and
laparoscopic. Ann surg 225: 422-431
67)Mahon D, Decadt B, Rhodes M (2003) Prospective
randomized trial of laparoscopic (transabdominal
preperitoneal) versus open (mesh) repair for bilateral and
recurrent inguinal hernia . Surg Endosc17: 1386-1390

68) Mohar D, Cook DJ, Eastwood S, Olkin I, Rennie D,

Stroup DF (1999) Improving the quality of reports of meta-
analysis. Lancet 354:1896-1900
69) Malagoni MA,Galgliardi
RJ.Hernias.In:Townsend,Beauchamp,Evers and Mattox
Sabiston Textbook of Surgery The Biological basis of
Modern Surgical Practice,17th edition @2004
Elsevier;Volume 2 Chapter 42 p 1199-1218.
70) McCormack K, Wake B, Perez J, Fraser C, Cook J,
Mcintosh E, Vale L, Grant A, laparoscopic surgery for
inguinal hernia repair: systematic review of effectiveness
and economic evaluation. Health Technol Assess.2005
Apr: 9(14):1-203, iii-iv.
71) Mc Minn RMH:Lasts Anatomy, regional and applied, 9th
edition,Churchill Living
stone, New york 1996.

72) Medical reserch council laparoscopic groin hernia trial

group. Cost-utility analysis of open versus laparoscopic
groin hernia repair: results from a multicenter randomized
clinical trials. Br J Surg. 2001 May : 88(5):653-61.
73) Memon MA,Fitzgibbons RJ: laparoscopic inguinal
hernia repair: transabdominal prepertioneal (TAPP)and
totally extraperitoneal (TEP). In scott-corner CEH (ed): The
sages manual. New York, springer, 1999.
74)Memon MA, Cooper NJ, Memon MI, Abrams KR (2003)
Metaanalysis of randomized clinical trials comparing open
and laparoscopic inguinal hernia repair. Br J Surg 90: 1479-
1492
75) Merello J,Guerra GA,Madriz J,Guerra GG(1997)
Laparoscopic TEP versus open Lichtenstein hernia repair:
randomized trial.Surg Endosc 11:545.
76) Mokete M & J J Earnshow 2001 . Evolution of Inguinal
hernia surgery
3practice.Post grad Medical Journal 77: 188-190.

77) Nathanson L, Adib R (1996) Randomized trial of open

and laparoscopic inguinal hernia repair. Surg Endosc
10:192.

78) Neumayer L, Giobbie-Hurder A, Jonasson O,et al. Open

mesh versus laparoscopic mesh repair of inguinal hernia.
N.Engl. J. Med.2004; 350:1819-1827.
79) Nicholson S 1999 . Inguinal hernia repair . British journal
of surgery 86 : 577-
578.

80) Nyhus LM: An anatomic reappraisal of the posterior

inguinal wall, with special consideration of the iliopubic tract
and its relation to groin hernias. Surg Clin North Am
44:1305, 1960.
81) Nyhus LM, pollak R, Bomback CT, et al: the pre
peritoneal approach and prosthetic buttress repair for
recurrent hernia. Ann surg 208:733, 1988.
82)Nyhus Llyod M, Robert E. Condon: the preperitoneal
approach and iliopubic tract
83) Nyhus LM. Indiviualisation oh hernia repair. A new era,
Surgery, 1993;114:102.

84) Nyhus Lloyd M , Robert E Codon Ed .The pre-peritoneal

approach & illiopubic
tract repair of inguinal hernia . Hernia J B Lippincott Co
philadelphia 1995:
154-180.

85) Occelli G, Barrat C, Catheline JM, Voreux JP, Cueto-

rozon R, Champault G (2000) laparoscopic treatment of
inguinal hernias: prospective evaluation of 757 cases treted
by a totally extraperitoneal route. Hernia 4: 81-84

86)Paganini AM, Lezoche E, Carle F, Favretti F, Feliciotto F,

Gesuita R, et al. (1998) A randomized controlled clinical
study of laparoscopic vs open tension-free inguinal hernia
repair. Surg Endosc 12: 979-986 Bietigheim 1998
87) Pande D P et al 1996. Collagen pattern study in Fascia
Transversalis of hernia
patients .Indian journal surgery july- aug :229-231.

88) Payne J, Izawa M, Glen P (1996) laparoscopic or

tension-freeinguinal hernia repair? A cost benefit analysis
of 200 prospective randomized patients. SAGES,
Philadelphia.

89) Philips EH, Arregui M, Carroll BJ, corbitt J, craftonWB,

Fallas MJ, Fillip C, Fitzgibbons RJ, Franklin MJ, McKernen B
(1995) incidence of complications following laparoscopic
hernioplaty. Surg Endosec 9:16-21.
90) Picchio M, Lombardi A, zolovkins A, Michelsons M, La
torre G (1999) tension free laparoscopic and open hernia
repair: randomized controlled trial of early results. World J
surg 23:1004-1009.
91) Ramshaw B, Abiad F, Voeller G, et al. Polyster mesh for
total extraperitoneal laparoscopic inguinal hernia repair:
initial experience in the united states. Endosc 2003: 17:498-
501
92) Raymond Pollock : “strangulation external hernia”
chapter 14 in Hernia, Nyhus
Lloyd M , Robert E Codon Ed , J B Lippincott Co
philadelphia 1995 : 273-283.

93) Robb H Rutledge 1998. Coper’s Ligament repair – A

25 years experience with
single technique for all groin hernia in adults .Surgery Vol
103. No 1: 1-10.

94) Robert E. Condon: “The anatomy of Inguinal hernia

and its relation to groin
hernia” chapter 2 in Hernia, Nyhus Lioyd M. and Robert
E.Condon: “Hernia”
Philadelphia J.B. Lippincott Company 1995; 18-64.

95) Robert J. Fitzgibbons Jr. inguinal hernia, chap 36,

Schwartz Principles of
surgery,In: Charles Brunicardi, Dana K. Anderson, Mc Graw
Hill 2005;1353-1393

96) Robert M: Zollinger Jr. Classification systems of groin

hernias. Rutkow IM,Hernia
repair, Philadelphia , W.B. Saunders co. 2003;83(5):1053-
65.
97) Rutkow IM, Robbins AW (1993) demodraphic,
classifactory, and socioeconomic aspects of hernia repair
in the united state. Surg clin north Am 73:413-426.
98)Sarli L, Pietra N, Choua O, Costi R, Thenasseril B, Giunta
A (1997) Confronto prospettico randomizzato tra
ernioplastica laparoscopica ed ernioplastica tension-free
secondo Lichtenstein Acta Biomed Ateneo Parmese68:5-10
99) Sarli L, lusco DR, Sansebastiano G, Costi R (2001)
Simultaneous repair of bilateral inguinal hernias: A
Prospective, randomized study of open, tension-free
versus laparoscopic approach.Surg Laparoscopic Endosc
Percutan Tech 11: 262-267.

100)Schmedt CG,Sauerland S,Bittner R. Comparison of

endoscopic procedures vs Lichtenstein and other open
mesh techniques for inguinal hernia repair A mete-analysis
of randomized controlled trials. Surg Endosc (2005) 19: 188
-199
101) Schmedt CG, Leibl BJ, Bittner R (2002) access-related
complications in laparoscopic surgery: tips and triks to
avoid trocar complications. Chirurg 73: 863-876
102) Schneider BE, Castilo JM, Villeges L, et al.
Laparoscopic totally extraperitoneal versus Lichestein
herniorraphy: cost comparison teaching hospitals. Surg.
Laparosc. Endoscope. Percutan. Tech. 2003: 13:261-267
103) Schwab ER, Quasebarth M, Brunt LM, prioperative
outcomes and complications of open versus laparoscopic
extraperitoneal inguinal hernia repair in a mature surgical
practice. Surg. Endosc 2004:18:221-227
104) Schwab JR, Beaird DA, Ramshaw B, et al. After 10
years and 1903 inguinal hernia, what is the outcome for
laparoscopic repair? Surg. Endosc.2002:16:1201-1206

105) Scott NW, Grant AM, Ross SJ, Smith A, Macintyre

IMC, O’Dwyer PJ (2000) Patient-assessed outcome up to
three months in a randomized controlled trial comparing
laparoscopic with open groin hernia repair. Hernia 4: 73-79
106) Scott NW, McCormack K, Grahm P, Go PM, Ross SJ,
Grant AM (2002) open mesh versus nonmesh for repair of
femoral and inguinal hernia. Cochrance database syst Rev
4CD002197.
107) Simmermacher Rk, Van Dyun EB, Clevers GJ, De
Varies LS, Van Vroonhoven TJMV (2000) preperitoneal
meah in groin hernia surgery: A randomized trial
emphasizing the surgical aspects of preperitoneal
placement via a laparoscopic (TEP) or grid-iron (Ugarhy)
approach. Hernia 4: 296-298.

108) Skandalakis J,Colborn G,Androulakis J,Embryologic

and anatomic basis of Inguinal herniorraphy.Surg Clin North
Am 74:799-836,1993.
109)Skandalakis John et al: “embryologic and anatomic
basis of inguinal herniorrhapy”
in Surg clin NA, Philadelphia: W.B.Sauders Co., 1993;73:799
-834.
110) Skandalakis John et al: “embryologic anatomy and
surgical applications of
preperitoneal space” in Surg clin NA,
Philadelphia:W.B.Sauders Co., feb-2000;
80(1):1-22.

101) Somen Das . A concise text book of surgery.1st Ed,

1994:1051-1068.

102) Stoppa RE: The treatment of complicated groin and

incisional hernias. World j surg 13:545, 1989.
103) Stoppa RE, Warlamount CK (1995) The preperitoneal
approach and prosthetic repair of groin hernias. In.Nyhus
LM, coldon RE (eds) hernia. 4th ed. JB lippincot,
Philadelphia PP 118-210.
104) Suter M, Martinet O (2002) Postoperative pulmonary
dysfunction after bilateral inguinal hernia repair: a
postoperative randomized study comparing the stoppa
procedure with laparoscopic total extraperitoneal repair
(TEP). Surg laparosc Endosec percutan Tech 12:420-425.

105) Swanstrom LL:laparoscopic hernia repair: the

importance of cost as an outcome measurement at the
century’s end. Surg clinnorth am 80:1341-1351, 2000.
106) Tamme C, Sceidbach H, Hampe C, Schneider C,
Ko’ckerling F (2003) Totally extraperitoneal endoscopic
inguinal hernia repair (TEP). Surg Endosc 17: 190-195
107) Tsang S, Normad R, Kaelin R (1994) Small bowel
obstruction: a morbid complication after laparoscopic
hernioplasty. Am surg 60:332-334.
108) Vale L, Grant A, McCormack K, Scott NW; EU hernia
trialists Collaboration. Cost-effectiveness of alternative
methods of surgical repair of inguinal hernia. Int. J Technol
assess Health care. 2004 Spring;20(2):192-200

109)Vatansev C,Belviramani M,Aksoy F,Tuncer S,Sahin

M,Karahan O(2002) The effects of different hernia repair
methods on postoperative pain medication and CRP
levels.Surg Laparosc Endosc Percutan Tech 12:243-246

110) Voyles CR, Hamilton BJ, Jhonson WD, et al: meta

analysis of laparoscopic inguinal hernia trials favors open
hernia repairwith prepertioneal mesh prosthesis. Am j surg
184:6-10, 2002.
111) Wellwood J, Sculpher MJ, Stoker D, nicholls GJ,
Geddes C, Whitehead A, singh R, et al. (1998) Randomized
controlled trial of laparoscopic versus open repair for
inguinal hernia: outcomes and cost. BMJ 317:103-110
112) Wright Dm, Kennedy A, Baxter JN, Fullarton GM, Fife
LM, Sunderland GT, O_Dwyer PJ (1996) Early outcome
after open versus extraperitoneal endoscopic tension-free
hernioplasty: A randomized clinical trial. Surgery 119: 552-
557.
113) Wright D, Paterson C, Scott N, Hair A, O_Dwyer PJ
(2002) Five year follow up of patients undergoing
laparoscopic or open groin hernia repair: a randomized
controlled trial. Ann Surg 235:333-337.
114) Zieren J, Zieren HU, Jacobi CA, Wenger FA, Muller JM
(1998) postoperative randomized study compairing
laparoscopic and open tension free inguinal hernia repair
with shouldice’s operation. Am J surg 175:330-333.
115) Zollinger RM Jr. Classification of ventral and groin
hernias, In:Fitzgibbons RJ Jr.,
Greenburg AG(eds). Nyhus and Condons Hernia,5th Ed,
Philadelphia, Lippincott
Williams and Wilkins, 2002; p71-79.

SURGICAL PAIN SCALES

We want to know how much pain or discomfort you
had within the last 24 hours as a result of
lumpectomy. Use a pen or pencil and draw an '.x" on
the lines below to indicate the average amount of
pain or discomfort you experienced. For instance, if
you did not have much pain today you would draw
an "x" down near the No Pain Sensation end of the
line. If you had a lot of pain today, you would make
an 'x" up towards the Most .Intense Pain Imaginable
end of the scale.

I. What was the average amount of pain you had

when you were a
0
10
No Pain Most
Intense Pain
Sensation Imaginable
2. How much pain did you have during your normal
activities
(for example, walking, climbing stairs, getting up
from a ch
0
10
No Pain Most
Intense Pain
Sensation Imaginable

3. How much pain did you have when you were

exercising, lifting objects you used to be able to lift
comfortably?
I have not done any of these activities today
0
10
No Pain Most
Intense Pain
Sensation Imaginable
4. How unpleasant or disturbing was the worst pain
that you had today ?
0
10

VISUAL ANALOGUE SCORE