Patients might visit their General Practitioner with a groin hernia, incisional, umbilical or ventral hernia, and ask about laparoscopic versus open repair techniques and their potential benefits or risks. Increasingly patients will have seen information about laparoscopic surgery in the media, or have relatives, friends or colleagues who have had a laparoscopic approach. So which is best?
Groin hernias
Can groin hernias be ignored and ‘watched’? Studies have repeatedly shown that groin hernias will continue to develop and become symptomatic, and of course waiting until the defect becomes larger is associated with increased recurrence rates once repaired and a very small risk of bowel incarceration/ strangulation. Obviously treatments are tailored to individual patients such that advice given to a 23 year old fit builder will be different to a 95 year old co-morbid patient.
Inguinal or femoral groin hernias can be approached by both an open or laparoscopic technique but both require a polypropylene mesh to avoid recurrences. Recurrence rates for experienced surgeons should be equal at less than 1%.
With the open method, an incision is made in the groin and muscles and fascia divided before excision of the hernial sac and mesh repair. This disruption causes the post-operative pain for up to 4 weeks and limits normal activity. Furthermore, nerves injured during this dissection can lead to chronic unremitting groin pain which is therefore much higher with open compared to the laparoscopic approach. With laparoscopic repairs only 3 tiny 5mm port sites are used and the mesh repair of the hernial defect performed without significant groin dissection, such that in my own recent audit of in excess of 500 patients that the average pain relief requirements are a mere 24 hours of simple paracetamol, with a good proportion requiring absolutely no analgesia, and average return to completely normal lifestyle by 11 days, with some returning to work within the first few days.
Because of the larger incision and muscular dissection in the groin where we all have more skin flora, the open approach is more susceptible to bleeding and wound infection (6.7% in a UK recent audit) and a proportion of these will develop catastrophic mesh infections, which is virtually unknown with the laparoscopic method. High risk groups such as diabetics, immunosuppressed etc might be better with a laparoscopic repair therefore.
With recurrent and bilateral hernias, there is absolutely no question that a laparoscopic repair is best, formally accepted by NICE guidelines in 2004.
When bilateral hernias are encountered, no new incisions are made and hence there is no ‘additional’ pain over a unilateral repair. In our very early publication in 2001, we found that actually 34% of clinically unilateral hernias are actually bilateral, and if the asymptomatic ‘undisclosed’ side is left then approximately 50% will go on to develop a symptomatic hernia within one year (and probably nearly all if you wait long enough since exactly the same intra-abdominal forces have been applied to both groins over the years). The advice therefore is to repair bilateral hernias laparoscopically at the same single operation, though this might be too painful with the open method.
When a patient has a recurrence of a previous open repair, there has already been an extensive groin dissection and particularly if mesh has been used previously, and the resultant scar tissue makes an open recurrent operation far more difficult with higher bleeding and wound infection rates, greater likelihood of injury to testicular blood vessels and nerves with resultant chronic groin pain, and higher rates of re-recurrence afterwards. With a laparoscopic recurrent hernia repair of a previous open approach, the intra-abdominal tissue planes are completely unscarred such that complication rates are no worse for primary or recurrent laparoscopic operations.
So when are open hernia repairs advocated? For a laparoscopic repair, the patient must have a general anaesthetic and some patient’s comorbidities will preclude them from a GA. My practice is thus to offer these patients an open sedation and local anaesthetic repair. In the early days of laparoscopic hernia repair, opponents to the technique quoted higher major intra-abdominal injury rates eg bowel and vascular injuries, quite possible as we were on our surgical learning curves in the infancy of general surgical laparoscopic operations. It is now apparent that these risks are extremely low eg 1 in 3000 for major vascular injury falling to 1 in 5000 once the laparoscopic surgeon has exceeded 100 repairs, and erroneously assumes no vascular injury with the open repair! With inadvertent laparoscopic bowel injury at 1 in 1500, rates do increase with previous open intra-abdominal surgery such as laparotomies, colectomies etc. Obviously these risks vary according to the ‘size’ and type of previous open operation, position of the scar, reason for the open surgery and numbers of open operations. An open minicholecystectomy scar or appendicectomy will have different risk level than multiple lower abdominal incisions for peritonitis and subsequent adhesions, and the latter should only be approached by the most experienced laparoscopic surgeons or an open repair advised once risks have been fully discussed with the patient.
What about very challenging groin hernias? Extremely large inguinoscrotal hernias can be very difficult to repair laparoscopically particularly if the bowel is incarcerated with adhesions within the scrotal hernial sac. Often I consent patients for a ‘hybrid’ approach whereby I commence laparoscopically but if I cannot reduce the scrotal contents, then I perform a small scrotal incision to free adhesions, before returning to complete the repair laparoscopically, with patients benefitting from the less painful laparoscopic repair, less risk of wound infection and huge scrotal haematomas often seen after the open inguinoscotal hernia repair, and earlier return to normal activities without chronic groin pain risks. Previous open prostatectomies and recurrence of a previous laparoscopic mesh hernia repair are very challenging laparoscopically due to potentially dense adhesions within the anticipated field of laparoscopic surgery. Nevertheless, these can be repaired laparoscopically using different techniques eg applying a second mesh fixed with glue etc, but again as previously stated with intra-abdominal adhesions, challenging hernias should only be approached by the most experienced laparoscopic surgeons.
Incisional hernias
By definition, incisional hernias are going to be more challenging laparoscopically since the patient will have had a previous operation, potentially with a varying degree of adhesions. However, often these patients have a much higher BMI with bigger omentum anteriorly ‘protecting’ the underlying bowel from adhesions to the hernia. Also some patients seem to develop more adhesions than others even when the surgeon might predict dense adhesions, though the surgery might actually turn out to be ‘surgeon friendly”! Therefore I always start laparoscopically with an extremely low rate of conversion to open, due to the benefits outweighing an open repair.
The benefits of laparoscopic incisional hernia repair again relate to post-operative pain and recovery essentially avoiding re-laparotomy to place a mesh via an open repair (with the disadvantage of more adhesions with possible later bowel obstructive episodes), though these benefits are more marginal laparoscopically since the mesh needs to be stapled to the abdominal wall musculature which is probably just as painful. For this reason I have recently started to piloting the use of glue for mesh fixation, and very early results seem to show some improvement in postoperative pain.
The greatest benefits relate to recurrence and mesh infection. Open suture repairs have recurrence rates as high as 40-50% and open mesh repairs 12-15% recurrence, but with the increased potential in an obese group of patients for disastrous mesh infections in a group likely to higher rates of diabetes, wound haematomas and hence wound and mesh infection, where the mesh then usually needs to be removed and at a later date the resultant re-recurrence repaired. On my published figures with laparoscopic mesh repair of incisional hernias requiring a mean mesh size of 12x12cm, our 2 year recurrence rate was a very acceptable 2.7%. Where the tiny laparoscopic incisions are necessarily away from the incisional hernia and the mesh never touches the patient’s skin flora, we have never seen a mesh infection. Sometimes with the laparoscopic approach we find additional undeclared hernias within a long laparotomy wound which would otherwise enlarge and become symptomatic, but which may never have been discovered with an open repair until they ‘recur’. Technically, with laparoscopic incisional hernia repair, the mesh is fixed with the abdominal wall distended by the necessary pneumoperitoneum, and when this is ‘deflated’ at the end of the operation, the mesh repair becomes tension-free as opposed to the open repair where the tight mesh becomes tighter as the patient awakes from the GA and muscle relaxation. This might in part explain higher recurrence rates.
Umbilical, Paraumbilical & Ventral hernias
The argument for the laparoscopic repair of these hernias is similar to incisional hernias, both with recurrence and infection. However, with small asymptomatic umbilical hernias it is very difficult to advocate a painful stapled laparoscopic mesh repair and not simply to wait and see whether the hernia enlarges. Actually the majority will and of course the larger the defect, the higher the resultant recurrence rate. It is tempting therefore to suggest an open suture repair of a small hernial defect, but again in our historical audit even these ‘small’ umbilical hernias are associated with a 23% two year recurrence rate. For these reasons I am currently trialling a new glue fixation of meshes laparoscopically placed, with some early success for symptomatic and enlarging umbilical and ventral hernias.
Summary – Laparoscopic versus open hernia repair for your patients
Personally as a laparoscopic enthusiast I would recommend laparoscopic mesh hernia repairs though would tailor my advice to individual patients. In those too unfit for GA, with dense complicated adhesions in complex hernias, or simply informed patient choice, then I would perform local anaesthetic and sedation open repairs. However this is the minority of patients; open outweighed by the laparoscopic earlier return to work with less post-operative discomfort, no chronic pain, lower wound complications, no mesh infections and generally lower recurrence rates. For larger obese patients potentially with diabetes, laparoscopic approaches show greater benefit by avoiding a larger incision, wound haematoma and infection and less mesh infection, and earlier mobilization reducing other post-operative complications. For more challenging hernia repairs I would advocate referral to an experienced laparoscopic surgeon with a proven and audited track record.
