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Burton et al. Mini-invasive Surg 2021;5:26 https://dx.doi.org/10.20517/2574-1225.2021.26 Page 5 of 8

planes. In our practice, a thorough discussion is conducted with the patient preoperatively on the risks and
benefits of concurrent repair of an asymptomatic contralateral hernia vs. waiting until symptoms develop to
pursue repair. Based on patient preference, repair of the contralateral asymptomatic side may or may not be
performed.

In reviews of both the Swedish and Danish hernia databases, femoral hernias were found in over 40% of
surgeries for recurrent groin hernias in women [26,27] . The preperitoneal dissection and the evaluation of the
myopectineal orifice in laparoscopic repair ensure any occult femoral hernias are evaluated and treated with
the mesh covering the space. For this reason, the EHS and Herniasurge groups encourage laparoscopic
groin hernia repairs in female patients, to reduce the risk of missed femoral hernias in open repairs where
the floor is commonly not opened and explored [19,20] . In our practice, female patients with groin hernias are
preferentially offered a laparoscopic or minimally invasive technique. If an open repair is performed, the
femoral space is always explored, evaluated, and repaired if necessary, using a modified Lichtenstein
technique.

COSTS OF REPAIR
Costs for inguinal hernia repair have been shown to be significantly lower for open inguinal hernia repair,
with differences being attributable to operating time as well as disposable material costs. As with many cost
calculations, results should be well scrutinized to determine applicability to a surgeon’s and patient’s specific
circumstances, the items being included in cost estimates, and the time frame for which costs are evaluated.
In the 2006 VA study evaluating overall healthcare costs over 2 years (including operative costs, subsequent
inpatient and outpatient care, and medications), Hynes et al. found laparoscopic repair was on average
[28]
$638 more than open, though not statistically significant. Similarly, in the retrospective study by Spencer
[29]
Netto et al. , open unilateral inguinal hernia repair was found to be significantly cheaper than laparoscopic
repair (median total cost, $3207.15 vs. $3723.66; P < 0.001), while bilateral repair costs were almost similar
(median total cost, $4574.02 vs. $4662.89; P = 0.827). In a prospective randomized control trial (RCT) by
Feliu et al. , laparoscopic bilateral inguinal hernia repair was found to be faster, with shorter hospital stays,
[30]
fewer recurrences, and lower postoperative complications than bilateral inguinal hernias repaired using the
Lichtenstein technique. In a meta-analysis by Schmedt et al. , operative time for a unilateral open
[31]
[27]
Lichtenstein repair was significantly shorter than laparoscopic repair (55.5 min vs. 65.7 min; P = 0.01) .
Due to variation in negotiated reimbursement rates, institutional cost evaluations by Jacobs and Morrison
showed $731 higher income generation for an ambulatory surgery center with laparoscopic repair when
compared to open, despite increased disposable costs of laparoscopic repair materials . Although repair of
[32]
unilateral groin hernia repair may be cheaper when performed open, it may net the performing institution
more income when performed laparoscopically. It does appear that bilateral repairs performed
laparoscopically are financially better. With the reduction of operative times and decreased costs of
disposable materials, use of laparoscopy could become similar if not more financially reasonable for the
repair of unilateral inguinal hernia repairs as well. By knowing personal operative times and hospital costs,
surgeons can adjust their surgical techniques to make the most financially reasonable as well as clinically
appropriate decision.

COMPLICATIONS
As previously stated, familiarity and expertise with a surgical technique are also reflected in surgical
outcomes. Well conducted studies and published analyses provide varying results on laparoscopic and open
[17]
inguinal hernia repair. In the 2004 RCT by Neumayer et al. with the Veterans Affairs (VA) medical
centers, comparing open mesh repair to laparoscopic mesh repair, the laparoscopic repair group had lower
postoperative pain and quicker return to normal activities, but higher rates of complications and