Laparoscopic Hernia Repair

In its first few years, laparoscopic herniorrhaphy was highly criticized for its unacceptably high recurrence rate, in some reports as high as 30% in one year. This was largely because after the development and popularity of Laparoscopic Cholecystectomy, there was a scramble to attempt and develop all types of procedures to be performed with the laparoscope. This procedure was originally performed by exposing the hernia from inside the abdomen and simply stuffing a piece of mesh in the defect with few if any stitches. Of course, the mesh "plug" would simply fall out. The present technique of laparoscopic herniorrhaphy, is a modification of a standard technique of open hernia repair with a mesh, now performed with a laparoscope. The long term statistics are not yet available, but it appears that this technique will have recurrence rates at least as good as standard open techniques if not better.

There are in fact two techniques of performing laparoscopic herniorrhaphy; trans-abdominal and total extra-peritoneal. Both will be discussed, however first I wish to explain the advantages and disadvantages of the laparoscopic approach to hernia repair in general. As I have explained above, the recurrence rate with the present techniques of laparoscopic hernia is as good, and perhaps better than that of open hernia repair. The laparoscopic approach allows complete broad exposure of the internal ring, the femoral ring, and other anatomic structures such that a large mesh can be applied over all of the possible areas of groin hernia formation and secured in place outside of the peritoneum. The mesh that can be used via laparoscopy is generally larger than that used for open repair.

During an open hernia repair with mesh, the mesh is sutured to the defect on its outside. In contrast, with a laparoscopic herniorrhaphy, the mesh is tacked or stapled to the defect on the inside. The natural stress on the repair during healing is from pressure inside the abdomen exerted outwards. The mesh sutured to the outside can be pushed away by this pressure exerted continuously against the repair. Conversely, this same pressure exerted against a mesh stapled to the inside of the defect laparoscopically serves to hold the mesh to the tissues during healing.

Good laparoscopy does require general anesthesia which is certainly not necessary for a standard open herniorrhaphy. However, this is not a significant drawback in a patient who is otherwise healthy and not a risk for general anesthesia.

Trans-abdominal laparoscopic herniorrhaphy involves repair of the hernia from inside the abdomen while viewing with the laparoscope. In contrast, total extra-peritoneal laparoscopic herniorrhaphy is done within the abdominal wall by creating a working space with a special balloon. Both procedures are equally effective at repairing all possible sources of abdominal wall herniation. The extra-peritoneal approach has the advantage of removing the risk of injury to intra-abdominal organs which is present, but very small, with the trans-abdominal approach. Both procedures are technically more difficult, require more equipment, and take longer than the usual standard open hernia repair with mesh.

The advantage of laparoscopic herniorrhaphy by either technique is in post-operative recovery. Following a standard open hernia tissue repair on one side most patients experience some degree of discomfort and in many cases this is quite significant. However, the degree of discomfort is significantly less on average when the repair is done with mesh. This is because a mesh repair does not place a lot of tension on the tissues while a tissue repair does. The most dramatic advantage of laparoscopic repair is seen following bilateral hernia repairs.

Patients almost always have significant pain and disability after bilateral tissue hernia repairs which often lasts for weeks. The discomfort after bilateral mesh repairs is somewhat less but still significant. Following laparoscopic bilateral hernia repairs patients are usually fully ambulatory with minimal pain and discomfort and may be back to work within one to two weeks as opposed to six to eight weeks following the other types of hernia surgery.

The other situation in which I find laparoscopic herniorrhaphy to be a major advantage is in the patient who has had several previous hernia operations from the outside with repeated recurrences. In these cases the laparoscopic approach affords the ability to repair the hernia from the inside, in tissues which have not been previously operated upon. This makes the surgery in fact much easier and greatly diminishes the risk of injury to vital structures which may not be identifiable in the scar tissue from the previous surgery.

In summary, laparoscopic herniorrhaphy is an excellent alternative to standard herniorrhaphy in selected patients. This procedure performed via the trans-abdominal or extra-peritoneal approach affords a repair with an equivalent and perhaps better recurrence rate than standard open techniques performed with or without mesh. Its disadvantages include the need for general anesthesia, its greater technical difficulty, its greater equipment requirement, and the need to enter the abdomen, at least for the trans-abdominal approach. Its advantage in permitting rapid post-operative recovery is most dramatic when compared to bilateral tissue repairs. It is also safer and easier in the context of a multiply recurrent hernia.

I encourage anyone interested in learning more to contact me via e-mail or telephone.


Steven P. Shikiar, MD, FACS email

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Last Update
March 20, 2013