Inguinal hernia repair in general surgical practice in 2004: more than laparoscopy, training is the keyword.

The most important outcome parameter after hernia repair remains the recurrence rate on the long term. Therefore, at present, the use of prosthetic material has replaced traditional tissue approximation repairs such as the Shouldice technique. Tension-free mesh repair is now the standard of care for inguinal hernia repair in adults (1). The Lichtenstein technique, introduced in 1984, is currently the most popular of different techniques (2): it is reproducible with minimal perioperative morbidity, it can be performed in day care (under local anesthesia) and has low recurrence rates (≤ 1%) on the long-term. Crucial is the adequate overlap of the posterior wall of the inguinal canal, especially 2cm medial to the pubic tubercle (3). Its superiority versus the Shouldice repair has been demonstrated in randomised controlled trials (RCTs) (4-6). In one recent paper (7), the incidence of chronic groin pain was substantially higher after Lichtenstein hernioplasty compared versus Shouldice repair, both performed by surgical trainees. However, this has not been confirmed in other trials and in a meta-analysis (8). The study by Aytac et al with a follow-up period of almost 4 years confirms in a retrospective manner that the results obtained in centers of excellence (= efficacy) can be reproduced in general surgical practice (= effectiveness). Therefore the Lichtenstein procedure is considered by many to be the gold standard for unilateral primary inguinal hernia repair and this is reflected in the national guidelines on inguinal hernia repair in the UK, France and the Netherlands (9-11). Many other tension-free methods have been described in the literature. Laparoscopic techniques, both transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP), have been investigated the most. To our knowledge, no RCTs comparing both laparoscopic techniques are available. We, as many others, prefer TEP, since it preserves peritoneal integrity. If deemed necessary, it can be combined with a diagnostic laparoscopy before starting the extraperitoneal dissection. Current evidence suggests faster rehabilitation but increased risk of rare but serious (intestinal and vascular) complications after laparoscopic mesh techniques. However controversy is still continuing, despite the availability of numerous RCTs and meta-analyses comparing open and laparoscopic tension-free techniques (12-15). The NICE guidelines in the UK recommend laparoscopic surgery as an option for bilateral and recurrent hernia, with a preference for TEP. It should be performed “. in those units with appropriately trained operating teams which regularly undertake these procedures. ” (9). Also in France and in the Netherlands, laparoscopy is considered a valuable option for these indications (10,11). The mesh-plug hernioplasty (16) is very popular in the USA, but a limited number of RCTs do not show any benefit versus the Lichtenstein mesh hernioplasty. The Prolene Hernia System (PHS) uses a double-leaved mesh with a connector. The deep part is placed preperitoneally and the superficial part is placed onlay as in the Lichtenstein procedure, thus using two different planes for dissection and mesh placement. There is one RCT available showing less postoperative pain and earlier recovery to normal activity versus the Lichtenstein procedure (17). Bearing in mind the expression “you do the best what you do the most”, does a general surgeon needs to train in laparoscopic inguinal hernia repair? We believe the answer is yes (18). Every surgeon needs to be familiar with both the anterior and posterior approach to the inguinal region. Indeed, it is more logical to approach the inguinal region posteriorly after a previous anterior repair, and vice versa, in order to minimise the risk for nerve damage, testicular atrophy and/or trauma to the deferent duct. If the principle of Stoppa with a giant prosthetic reinforcement of the visceral sac (19) and reinforcement of the whole myopectineal orifice of Fruchaud can be obtained by minimal invasive means with low morbidity and low recurrence rates on the long term, the laparoscopic procedure is to be preferred versus the open posterior approach. Laparoscopic techniques in general and TEP in particular have a steep learning curve, the latter due to limited working space and the specific anatomical landmarks. Therefore, instead of discouraging and limiting the use of laparoInguinal hernia repair in general surgical practice in 2004 : more than laparoscopy, training is the keyword.