It is now technically possible to repair virtually any hernia by a laparoscopic approach. There continues to be some debate in surgical circles as to whether a laparoscopic repair is the appropriate type of surgery for certain types of hernia. Generally, I like to repair hernias laparoscopically wherever possible.
The greatest advantage of laparoscopic surgery is a reduction in post-operative pain and a more rapid return to normal activities. All hernia repairs are now carried out using the insertion of a prosthetic mesh. The meshes used are one of two types; either polypropylene or polyester. Polyester meshes have been used in Europe for some time but have only recently been introduced to Australia. Polyester meshes have certain characteristics that make them better for hernia repair. They are easy to handle from the surgeon’s point of view and they are less likely to shrink. I therefore use polyester mesh for all of my hernia repairs.
Inguinal or groin hernias can be repaired laparoscopically with a couple of different techniques. The most common technique in Australia is the laparoscopic extraperitoneal repair (TEP repair) whereas in Europe they have tended to favour the intra-abdominal repair (TAP repair). The TEP repair is technically more demanding but avoids the risks of entering the abdominal cavity. Because the TEP repair is technically more difficult, historically the recurrence rates have been higher than open hernia repair, but with the introduction of new mesh materials and changes in surgical technique, the long term results are now as good as – if not better – than open inguinal hernia repair. However it should be emphasised that TEP inguinal hernia repair should be performed by an experienced laparoscopic surgeon with appropriate training in the technique. TEP inguinal hernia repair is not possible in some patients, particularly men who have had prostate surgery, and in these circumstances a TAP type repair offers an appropriate laparoscopic alternative.
Laparoscopic hernia repair would be considered the gold standard operation for recurrent groin hernias and also for patients with bilateral groin hernias. Up to 25% of patients with a unilateral groin hernia have a hernia on the other side when examined and investigated.
A new and exciting area of laparoscopic hernia repair has been laparoscopic repair of umbilical and incisional hernias. These types of repair allow the hernia defect to be examined from the inside and as is often the case with incisional hernias, other smaller hernias which are not clinically apparent, are seen laparoscopically. This allows a mesh of appropriate size to be placed to cover both the main defect and also the smaller defects which, if untreated, would eventually present as recurrent incisional hernias in years to come. Laparoscopically repair of incisional hernias avoids the need for major abdominal incisions leading to faster patient recovery and less post-operative pain. Laparoscopic repair of these types of hernias does require the use of special non-adherent mesh that can be placed inside the abdominal cavity. Laparoscopic repair of incisional hernias has been shown to have a lower recurrence rate and lower infection rate than the more traditional open operation.
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