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Cartersville Surgical Associates, PC
970 Joe Frank Harris Parkway
Cartersville, GA 30120
Phone: 770.386.1261
Fax: 770.386.3873
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Hernia repair is the most common general surgical operation in the United States, with approximately 800,000 operations performed per year. Over the past decade, minimally invasive surgical principles have been applied to inquinal and most recently ventral hernia repair. Early in the laparoscopic inquinal hernia experience, there was concern over the recurrence rate of hernias using the laparoscopic approach. A review of the medical literature will results in a wide range of risk of recurrence, from less than 1% to as much as 15%. Historically, hernia repairs were done as primary tissue repairs. These repairs were repairs using only tissue, with no reinforcing material. Primary tissue repairs are plagued with increased tension on the repair which results in more pain and a higher likelihood of recurrence.
The introduction of tension free repairs utilizing mesh to cover the inquinal floor resulted in lower recurrence rates and less discomfort. The Lichtenstein repair, introduced in 1986, is the most commonly utilized hernia repair in the United States. This is an onlay mesh repair, using an open anterior approach. The repair is an easy repair for young surgeons to learn and can be done under local anesthesia. Recurrence rates for this repair have been less than 1%. Operative time is usually on the order of 45-60 minutes, and is done as an outpatient procedure. Most patients resume normal activities 10-14 days post operatively, though our recommendation is to do no lifting greater than 30 pounds for 4 weeks post op.
The laparoscopic approach to hernia repair was derived as an extension of the Stoppa repair, which is an open preperitoneal repair. There are 2 approaches to the preperitoneal space from a laparoscopic perspective. The first approach is the transabdominal approach (TAPP), and secondly, the total extraperitoneal approach (TEP). We utilize the TEP approach because using this approach, we do not have to enter the abdominal cavity, and there is less risk of injury to intra-abdominal structures, as well as a lower risk of adhesions. Though the laparoscopic repairs initially had a steep learning curve, this repair has evolved into an effective preperitoneal repair. A recent meta-analysis of hernia repairs, reviewing 14 randomized trials demonstrated that laparoscopic repairs take longer and cost more, however there is less pain and a quicker return to full function. Other studies and anecdotal experience tells us that there is not a significantly increased operative time with the laparoscopic approach. A separate meta-analysis performed by the EU Hernia Trialists Collaboration reviewed 4165 patients from 25 randomized trials and noted that laparoscopic repair was associated with a quicker return to activity, reduction of persitent pain, and a lower recurrence rate compared with open mesh repairs.
The newest frontier in hernia surgery has become changes in mesh utilized for tension free herniorrhaphys. We have been using the Ethicon Ultra Pro mesh, a new combination monocryl and prolene mesh which is more supple and conforms to the tissue better, resulting in less pain. Scientific investigations regarding the strength of various mesh repairs indicates that historically we have overengineered the mesh for strength
and in fact softer more supple material will cause less pain and work as well as stronger more rigid mesh.
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