Chain of Events Leading to the Development of the Current Techniques of Laparoscopic Inguinal Hernia Repair: The Time Was Ripe

Abstract

In the late 1980s, laparoscopic cholecystectomy was started. At the time, this was radical and most surgeons opposed it. A few were courageous enough to believe in it and adopted it early on. This was a major milestone in surgery. Today, just over 30 years later, surgery residents in the USA rarely see open cholecystectomies, and many never see an open common bile duct exploration. In the USA, cholecystectomy is the most common general surgical procedure. Inguinal hernia repair is probably the second most common general surgical procedure, and approximately 690,000 groin hernia repairs were being performed annually in the USA in 1991. At that time nearly all were performed open, and patients stayed in the hospital for postoperative care. Recurrences were high. Today, in the USA, the vast majorities are performed as an outpatient procedure. Most are still performed with a variety of open approaches. The number of different techniques for inguinal hernia repair has greatly increased with both laparoscopic and open surgeries. There is no uniform agreement on the best repair. There is controversy over open repairs and controversies over the laparoscopic approaches. In fact there are more approaches today than 30 years ago. The penetration of the laparoscopic approach in the USA is probably only about 20–30%. This penetration is higher in some countries such as Germany than in others. In some countries with limited medical resources, this approach is not affordable. The laparoscopic approach requires general anesthesia that adds to the cost. Even without factoring in anesthesia, it is more costly to perform due to the added costs of laparoscopy and many of the specialty tools such as tacking devices, balloons, glues, modified meshes, etc. Nonetheless, in theory, the preperitoneal placement of mesh is probably the most anatomical. It is less painful and provides a quicker recovery with the lowest recurrence when done properly using large meshes. Even with the laparoscopic approaches, there is controversy over the best approach. Should a TEP or TAPP be done, what type and size of mesh should be used, and is fixation necessary? How extensive should the dissection be? Will we be seeing mesh migration such as in the gynecologic pelvic suspension procedures and hiatal hernia repairs?