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INDICATIONS

Laparoscopic inguinal hernia repair may be offered to patients who desire a rapid return to full activity, have bilateral inguinal hernias, or have a recurrent hernia where an open anterior approach has failed. The main benefits of laparoscopic repair are a decrease in postoperative pain and an improved time to recovery compared with the open approach. This advantage is particularly beneficial in patients with bilateral hernias because both hernias can be repaired under the same anesthetic without an increase in postoperative pain and disability. The benefit to repairing a recurrent inguinal hernia laparoscopically is that the laparoscopic approach can identify the exact location of the recurrence from the interior of the groin and the defect can be patched without extensive dissection through scarred tissue.

The disadvantages of the laparoscopic approach compared to the open approach are its increased cost and need for general anesthesia. In addition, the laparoscopic procedure is more difficult to learn than open repair, which may result in more complications and early recurrence before the “learning curve” is surpassed. These disadvantages have made laparoscopic inguinal hernia repair less frequently applied than laparoscopic cholecystectomy or laparoscopic appendectomy.

PREOPERATIVE PREPARATION

Patients with an inguinal hernia describe the appearance of a groin bulge with minimal or mild groin discomfort. The bulge is usually intermittent in appearance—that is, it generally disappears when the patient is recumbent and reappears when standing. With time the bulge enlarges. Radiographic confirmation is not necessary if the surgeon can see the hernia or palpate it on physical exam. Small inguinal and femoral hernias are not always obvious on physical exam. Groin ultrasound, computed tomography, or magnetic resonance imaging may help confirm the diagnosis, but they are only 80% to 90% sensitive and less specific. An occasional patient may need laparoscopy to diagnose or disprove inguinal hernia. If present, the hernia can be repaired using the intraperitoneal approach.

There are several kinds of inguinal hernia. The laparoscopic approach is appropriate for the three most common types: indirect, direct, and femoral hernia. It is not necessary to differentiate between an indirect and direct inguinal hernia, preoperatively. A femoral hernia will usually be apparent on physical exam, but if not, the laparoscopic approach allows the surgeon to accurately identify the type of hernia and effectively tailor the repair to the pathology. Large and long-standing inguinal hernias, such as scrotal hernias, pantaloon hernias (direct and indirect inguinal hernia combined) and sliding hernias, require more skill to repair with a minimally invasive technique. A painful inguinal hernia that will not reduce opens the possibility of bowel strangulation and should be explored urgently. The minimally invasive approach is not well suited for this indication except in the most expert surgeons’ hands. In this setting an expert may choose to reduce the incarcerated bowel laparoscopically. If it “pinks up,” not requiring resection, the surgeon may fix the hernia transperitoneally or “convert” to ...

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