Evidence - Laparoscopic totally extra-peritoneal (TEP) inguinal hernia repair with DynaMesh ENDOLAP 3D

Minimally invasive hernia surgery is a safe and widely used procedure. Comparison of total extraperitoneal (TEP) with transabdominal preperitoneal (TAPP) repair shows no superiority for either procedure; both techniques are acceptable. Lightweight meshes show promising benefits, and while biological meshes are a novel concept, they lack randomized controlled trials. Randomized controlled trials have demonstrated that mesh fixation is detrimental in most hernias. However, a surgical standard has been lacking to date.

Indication:

• Recurrent hernia after initial anterior procedure
• Bilateral inguinal hernia
• Primary inguinal hernia after appropriate information about alternative procedures

Contraindications:

• Previous procedures in the lower abdomen because this hinders the dissection of the parietal peritoneum off the abdominal wall.
• Scrotal or incarcerated/irreducible hernias

Benefits compared to open mesh procedures (Lichtenstein):

• No difference in mean recurrence rate (2%)
• Less frequent chronic pain
• Shorter convalescence
• No postoperative rest required

Drawbacks compared to open mesh procedures (Lichtenstein):

• Surgeon experience has a bigger impact on recurrence rate
• More expensive
• General anesthesia
• Longer operating time
• Major complications possible (injuries to nerves, bowel, vessel, and bladder)
• Drawn out learning curve
• Limited availability in specialized centers

Benefits compared to TAPP procedure:

• Adhesions and injury to intraabdominal organs can be avoided.
• Trend toward shorter hospital stay

Meshes

• At this time there are not enough clinical data for clear-cut evidence-based recommendation of particular meshes.
• From experimental data, we know that unlike lightweight meshes, heavy-weight meshes trigger more pronounced scarring and subsequent shrinkage.
• Controlled clinical trials noted more short-term benefits for the light-weight meshes, particularly less seromas, less pain and earlier return to the activities of daily living.

Mesh fixation

• In herniorraphy meshes may be fixated by suture, various absorbable and nonabsorbable tacks, and sealants. According to the guidelines for minimally invasive inguinal hernia repair (Bittner et al. 2011a) the recurrence rate after TAPP and TEP (evidence level 1B) does not increase when there is no fixation; however, this is only true for defect diameters 3 cm and less. If the mesh is fixated by metal tacks the risk of acute or chronic groin pain may increase. Mesh fixation by fibrin sealant decreases the rate of acute and chronic groin pain without increasing the risk of recurrence.
• In defects up to 3 cm repaired by TAPP and TEP the mesh does not have to be fixated. In larger defects where fixation is deemed necessary, this should be by fibrin sealant since it reduces acute and chronic postoperative pain.
• Only very large medial inguinal hernias, bilateral medial hernias and large scrotal hernias require mesh fixation by tacks. In these cases, the mesh should be larger sized (12 x 17 cm).

Laparoscopic Inguinal Hernia Repair - Does the Choice of Self-fixated Mesh Matter?

Laparoendoscopic Single-site Versus Three Port Totally Extraperitoneal Hernia Repair: A Prospective Double Blinded Randomized Clinical Trial

Conventional Versus Robot Assisted Laparoscopic Inguinal Hernia Repair

Postoperative Pain and Recurrences After Totally Extraperitoneal Endoscopic (TEP) vs. Lichtenstein Hernioplasty in Female Inguinal Hernia Repair: a Prospective Randomized Multi-center Study

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