What should be the correct indications for laparoscopic inguinal hernia repair?

Abstract

I appreciate the comments of Sabuncuoglu et al. [1] about my article [2]. They raised several important issues regarding indications for laparoscopic hernia repair, primary end points of hernia surgery, and the difficulties of urologic surgery after laparoscopic and endoscopic hernia repair. The historical studies on laparoscopic and open hernia repair techniques presented by Sabuncuoglu et al. do not analyze the different hernia types (e.g., medial and lateral inguinal hernias, scrotal hernias, incarcerated hernias, hernias after radical prostatectomy and recurrences following TAPP and TEP). Therefore, the statements of the Hernia Trialists Collaboration study are restricted [3]. Nevertheless, the data suggested less persistent postoperative pain and numbness following laparoscopic repair and the patients were able to return to their usual activities more quickly. According to the study, there was no apparent difference in recurrence rate between laparoscopic and open mesh methods of hernia repair. However, the transferability of the results is limited. The European Hernia Society (EHS) has recommended TAPP and TEP as standard procedures for repairing bilateral and recurrent hernias after anterior repair, and inguinal hernias in females [4]. In addition, the International Endohernia Society (IEHS) recommended TAPP and TEP as treatment options for complicated hernias (scrotal hernias, incarcerated hernias, hernias after radical prostatectomy, and recurrent hernias after TAPP and TEP procedures), if the repair is performed by a surgeon experienced in laparoscopic and endoscopic hernia repair [5]. Besides the recurrence rate, a high level of patient satisfaction with the outcome of their repair is an important primary end point in hernia surgery. According to my retrospective study, 96.9 % of all patients were satisfied with the result of their modified TAPP. Only 1.5 % was dissatisfied due to hernia recurrence, persistent pain, or postoperative complications. A radical prostatectomy after a bilateral laparoscopic or endoscopic hernia repair and a TAPP or TEP after a radical prostatectomy are challenging and time-consuming interventions. A modification of the surgical repair technique is necessary. There is necessarily a steep learning curve for these procedures. The repair should be done only by surgeons who have extensive experience in laparoscopic and endoscopic hernia repair [5]. According to single-case reports [6, 7], the fibrotic reaction of the implanted mesh after endoscopic and laparoscopic hernia repair makes urologic cancer surgery complicated. According to these reports, the preparation of the preperitoneal space should be nearly impossible [1]. In contrast, Stolzenburg et al. [8] presented a large series of 2,000 endoscopic extraperitoneal radical prostatectomy (EERPE) procedures, including 50 patients who had had a prior endoscopic/laparoscopic hernioplasty, with no conversions to an open procedure and the rates of intraand postoperative complications were not increased. We agree with these authors that EERPE after TAPP and TEP is a safe and effective procedure when port placement and the preparation of the retropubic space are modified. For this procedure, a surgeon experienced not only in laparoscopic hernia repair but also in laparoscopic radical prostatectomy is needed. Replying to the question of how to manage hernia repair in patients with risk factors for pelvic surgery, to our W. K. J. Peitsch (&) Klinik fur Allgemeinund Viszeralchirurgie, Katholisches Krankenhaus St. Josef, Kliniken Essen Sud, Propsteistr. 2, 45239 Essen, Germany e-mail: wkjpeitsch@t-online.de