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Page 6 of 8 Burton et al. Mini-invasive Surg 2021;5:26 https://dx.doi.org/10.20517/2574-1225.2021.26

recurrences. These findings have been questioned, as the size of the mesh used for laparoscopic repair was
[33]
not standardized and may have played a role in higher laparoscopic recurrences . As well, the study
included operating surgeons not sufficiently adept at laparoscopic repair (only 25 prior repairs were needed
to qualify as a surgeon in the study) and posthoc analysis found significant differences in recurrence rates
between surgeons who had performed fewer than 250 laparoscopic repairs vs. those who had performed
[17]
greater than 250 repairs (> 10% recurrence vs. < 5% recurrence; P < 0.001) . In the 2010 meta-analysis by
Karthikesalingam et al. of four RCTs comparing various open repairs to laparoscopic (TEP and TAPP)
[34]
inguinal hernia repair, recurrence rates, chronic pain, hematoma formation, and need for additional
operations were the same, while laparoscopic repair had less postoperative pain, fewer wound infections,
faster recovery and return to work, but a longer operative time. In the 2005 meta-analysis by Schmedt
et al. comparing laparoscopic (TEP and TAPP) techniques to the Lichtenstein repair, laparoscopy had
[31]
lower rates of wound infection, hematoma formation, nerve injury and chronic pain, and quicker return to
work and daily activities, while open repair had fewer recurrences and seromas, and shorter operative times.
In further analysis with removing the results from the 2004 Neumayer study, regarding the difference in
recurrence rates of open and laparoscopic repairs, there was no statistically significant difference between
laparoscopic and open repairs [17,29] . Consistently seen in these studies, laparoscopic repair appears to have
quicker return to work as well as less postoperative pain.

WHEN TO UTILIZE EACH TECHNIQUE
There are many variables to take into consideration, such as patient gender, type of groin hernia, wound
class, whether it is unilateral or bilateral, and prior surgeries, when deciding on the method of repair. As
well, a surgeon must take into account personal expertise with each surgical technique and determine the
best type of repair for the clinical scenario. With that acknowledgement, in order to develop expertise,
surgeons must progress through a learning curve and necessitate the need to accept longer operative times,
higher costs when using adjunct disposables such as a dissecting balloon for TEP repair, and potentially
higher incidences of complications such as seromas and hematomas. Once a surgeon feels competent with
both laparoscopic and open techniques, an evaluation of personal outcomes should be made to determine
what is the best method of repair to offer each patient. With equal expertise in open and laparoscopic
repairs and evaluation of published data, patients with bilateral groin hernias, patients suspected of
contralateral groin hernias, female patients with groin hernias, and patients with recurrent hernias after
prior anterior mesh repair are offered minimally invasive and/or laparoscopic repair [Figure 1]. Patients
with contraindications to general anesthesia or prior preperitoneal repair are offered an open Lichtenstein
repair. Men with unilateral non-recurrent groin hernias or patients with histories of pelvic surgery and
scarring are offered both open and minimally invasive/laparoscopic repairs, and differing risks and benefits
are evaluated and weighed by the patient and surgeon to determine a mutually agreed upon method of
repair.

There are many possible interventions when addressing inguinal hernias. There are variations of both open
and laparoscopic techniques - from mesh to tissue repair and transabdominal to totally extra-peritoneal.
Each surgeon must consider patient factors along with their own skill set and comfort level when deciding
which technique to use. It is beneficial for surgeons to be well acquainted and facile with both open and
laparoscopic techniques to provide a tailored approach to each patient. Like most things, the fact that there
are multiple ways to perform a procedure is indicative that there may not be one truly best way. Equally
important is that the surgeon becomes facile with the surgical technique, is knowledgeable of the anatomy
and surgical principles of the operation, acknowledges the clinical situation, and follows the patients’
outcomes.