Table of contents Introduction Chapter 1 Perioperative management: what is the evidence for antibiotic and thromboembolic prophylaxis in laparoscopic inguinal hernia surgery? Chapter 2 Technical key points in transabdominal preperitoneal patch plasty (TAPP) Chapter 3 Technical key points: total extraperitoneal patch plasty (TEP) repair Chapter 4 TEP versus TAPP: which is better for the patient? Chapter 5 Laparoscopic surgery in complicated hernia: feasibility, risks, and benefits Chapter 6 Mesh size and recurrence: what is the optimal size? Chapter 7 Selection of mesh material Chapter 8 Cutting or not cutting of mesh: does it influence the recurrence rate? Chapter 9 Mesh fixation modalities: is there an association with acute or chronic pain? Chapter 10 Risk factors and prevention of acute and chronic pain Chapter 11 Urogenital complications associated with laparoscopic/endoscopic hernia repair Chapter 12 Intraperitoneal onlay mesh (IPOM) for inguinal hernia repair—still a therapeutic option? Chapter 13 Role for open preperitoneal mesh repair in the era of laparoscopic inguinal hernia repair Chapter 14 Sportsman hernia—diagnosis and treatment Introduction Governments and health insurers increasingly demand transparent quality-control mechanisms. A new type of reimbursement, “pay for performance,” is being discussed. Therefore, the development and implementation of guidelines constitutes an important step toward the introduction of optimal diagnostic and therapeutic concepts with the goal of improving the quality of treatment. Guidelines should define standards to help the surgeon in his or her daily work by finding the best surgical strategy for his patient. The Guidelines are essentially evidence-based (Evidence-Based Medicine, EBM) but also allow use of “eminence”-based statements in a critical way. Already 200 years ago, P.Ch.A. Louis postulated: “Thus, a therapeutic agent cannot be employed with any discrimination or probability of success in a given case, unless its general efficacy, in analogous cases, has been previously ascertained; therefore I conceive that without the aid of statistics nothing like real medicine is possible.” Opponents of EBM argue that, in view of the uniqueness of the patient, clinical studies are of little value. However, despite these criticisms, it is generally accepted today that classifications, rules, laws, and scientific theories cannot be developed without identifying the common features of large patient populations or diseases; variety in itself warrants statistical methods. To answer specific questions in a particular case, the surgeon should be able to draw from pertinent, high-quality, well-documented biometric studies to choose the most appropriate therapy for his patient. However, because the studies often suffer from methodical flaws, especially from the heterogeneity of data, it needs caution and deep clinical experience when applying results of EBM to an individual case, even if elaborate meta-analytic techniques have been developed to allow for a differential evaluation of the study results. The authors of the following guidelines are aware of these problems and are conscious of the responsibility that they undertake when describing the scientific state-of-the-art in laparoscopic/endoscopic inguinal hernia repair according to the best external evidence available and when making recommendations for the individual case. Inguinal hernia repair is the most frequent operation in general and visceral surgery worldwide. In the western countries, including the United States, more than 1.5 millions procedures are performed every year. Thus, hernia repair not only affects the individual patient but also has a significant socioeconomic relevance and an important impact on the costs for the health care system. During the third meeting of the network International Endohernia Society (IEHS) held in Stuttgart, January 2008, live demonstrations of hernia repair performed by ten surgeons from four continents showed that guidelines for standardization of operative technique, especially regarding teaching, are urgently needed. This prompted a discussion about this challenge, which was pursued during the meeting of AHS in Scottsdale/Arizona, 2008, with the attendance of R. Fitzgibbons, M. Arregui, F. Köckerling, and P. Chowbey. The need for guidelines was unanimously acknowledged but with a focus on technique and special problems in transabdominal preperitoneal patch plasty (TAPP) and total extraperitoneal patch plasty (TEP). The authors were aware that some overlapping or interference with the EHS Guidelines was not completely avoidable but should be limited as far as possible. Regarding this problem, the authors appreciate the valuable contributions that M. Miserez gave during the past year. We started the guideline development process in June 2008 by collecting the most important questions and assembling the most qualified experts in laparoscopic hernia repair. An inviting letter was sent to all well-known laparoscopic hernia specialists who have made outstanding contributions to hernia surgery published in peer-review journals to participate in a Consensus Conference organized for February 2009 in Delhi by P. Chowbey. The following questions were asked: Are you willing to participate? Are you interested in an active participation? In your opinion what are the most important questions in endoscopic hernia surgery? (e.g., TAPP or TEP, to fix or not to fix, etc.). Are you (you can create a working group) ready to answer one of these questions according to the literature and your own data? Thus, you are able to give a recommendation at the conference. If yes, please inform us about the topic you want to look for. On the basis of the answers received, 14 topics were identified as most important and 14 surgeons declared their willingness to draft the respective guideline. In a second step, the experts were asked to: (1) search the literature regarding the topic at hand, and (2) graduation of the papers according to the Oxford hierarchy of evidence (following the advice of Dr. S. Sauerland) as outlined below consisting of the following five levels: 1A. Systematic review of RCTs (with consistent results from individual studies). 1B. RCTs (of good quality). 2A. Systematic review of 2B studies (with consistent results from individual studies). 2B. Prospective comparative studies (or RCT of poorer quality). 2C. Outcome studies (analyses of large registries, population-based data, etc.). 3. Retrospective, comparative studies, case–control studies. 4. Case series (i.e., studies without control group). 5. Expert opinion, animal or lab experiments. (3) For the recommendations, use the following grading scale: Consistent level 1 studies => strict recommendations (“standard”; “surgeons must do it”). Consistent level 2 or 3 studies or extrapolations from level 1 studies => less strict wording (“recommendation”; “surgeons should do it”). Level 4 studies or extrapolations from level 2 or 3 studies => vague wording (“option”; “surgeons can do it”). Level 5 evidence or troublingly inconsistent or inconclusive studies at any level => no recommendation at all, describe options. However, there often is a need to upgrade or downgrade a recommendation, because the outcome is so important or the clinical preference is so strong. This is possible but needs to be explained in the commentary text, and (4) Prepare a paper to present at the Consensus Conference in Delhi. In Delhi (Consensus Conference and fourth meeting of the International Endohernia Society (IEHS), February 18–21, 2009), the papers were discussed first in the round of experts and one day later during the plenary session attended by several hundreds of participants. During the following months, the authors drafted the first version of their specific chapter, including all the suggestions they had received during the conference. These first versions had been sent to our biometric advisor, Dr. S. Sauerland, for review and then were distributed to all the other experts for critics, remarks, and supplements. During these weeks, countless mails and revisions of papers were exchanged to achieve definitive guidelines that all experts could agree upon. In addition, two meetings that brought together most of the authors and the steering committee took place in September 2009 during the AHS/EHS/APHS meeting in Berlin and in December 2009 in Stuttgart respectively. The guidelines focus on technique and perioperative management of laparoscopic/endoscopic inguinal hernia repair. They are not intended as competing alternatives to the EHS guidelines, although there is some overlap, especially regarding risk factors for pain and selection of mesh. The advantages of the guidelines presented here are: (1) Papers published until 01.02.2009 could be included, therefore, literature used here is more up to date; (2) The authors come from Europe, America, and Asia; therefore, the guidelines are, effectively, global; (3) The authors use the Oxford hierarchy of evidence comprising five levels; thus, big case series could be included, all together giving a more realistic representation of generally used practice. Steering Committee Prof. Reinhard Bittner, MD. Professor of Surgery, Dr.h.c. mult., FRCS; visceral surgeon, em. Director, Department of Visceral and General Surgery, Marienhospital Stuttgart. Seniordirector, Center of Minimally Invasive Surgery, Bethesda Krankenhaus Stuttgart. More than 350 original articles and more than 600 scientific lectures. Approximately 50 live demonstrations of TAPP, Cholecystectomy, Colon Resection in 15 countries in Europe and Asia. Former President of the German Society for Visceral and General Surgery. Former President of the German Association of Minimal Surgery. Vice-President and Former Congress President of the German Hernia Society. Dr. Jan Kukleta, MD. General, visceral, abdominal wall surgeon. Klinik im Park, Zürich, Switzerland. Director of the Endoscopic Training Center Zürich. Lecturer at the ESI Hamburg and Elancourt Paris. More than 50 hernia-specific contributions at international meetings. Dr. Wolfgang Reinpold, MD. General surgeon, Director of the Department of Surgery, Gross Sand Hospital Hamburg; Director of the Hernia Center in Hamburg Wilhelmsburg. Special interest: risk factors for pain and pain treatment after hernia repair. One randomized and seven prospective studies on pain and new techniques in inguinal and incisional hernia repair, whether open or laparoscopic. More than 30 hernia specific presentations at international meetings. Congress President elect of the German Hernia Society. Working Group Maurice E. Arregui, MD, FACS. Department Chair, General Surgery, St. Vincent Hospital, Indianapolis, Indiana, USA. Former President of the American Hernia Society. Co-Editor of Surgical Laparoscopy, Endoscopy, and Percutaneous Techniques. 97 Original Articles in Peer Review Journals. 43 book chapters. Thue Bisgaard, MD. Associated Professor, Chief Surgeon, Department of Surgery, Koge Hospital, University of Copenhagen. 52 publications in peer-reviewed journals. Three book chapters. Assistant editor: Ugeskrift for Laeger and Danish Medical Bulletin. Member of steering committee of the Danish National Hernia Database, chairman of the ventral hernia database. Pradeep Chowbey, MD, Dr.h.c., FACS. Director of Minimal Access, Metabolic, and Bariatric Surgery, Max Healthcare Institute Ltd., Saket, New Delhi, India. Honorary Surgeon to the President of India. Surgeon to His Holiness Dalai Lama. Founder President of the Asia–Pacific Hernia Society. Former President of the Obesity & Metabolic Surgery Society of India. Trustee & Former President of the Indian Association of Gastrointestinal Endo-Surgeons. President elect of the Asia Pacific Metabolic & Bariatric Surgical Society. 75 original articles. Two books. Educational set of 15 CD-ROMs. Editor: Journal of Minimal Access Surgery. Editorial Board: Hernia. Obesity Journal. Indian Journal of Surgery. Journal of Society of Endoscopic and Laparoscopic Surgeons of Asia. Moshe Dudai, MD, FACS. Assistant Professor of Surgery, USUHS Bethesda, USA. Consultant of Elisha Medical Center in Haifa, Israel. President of European Association of Video Surgeons. Video Editor of the Journal of Surgical Laparoscopy Endoscopy & Percutaneous Techniques. 14 publications. Three book chapters. 268 scientific lectures. Prof. George S. Ferzli, MD, FACS. Professor of Surgery, SUNY Health Science Center, Brooklyn, NY, USA. Chairman of the Department of Surgery at Lutheran Medical Center. Director of the Medical Fellowship Program. More than 100 original articles in peer-reviewed journals. More than 10 chapters in medical textbooks. Prof. Robert J. Fitzgibbons, MD, FACS. Harry E. Stuckenhoff Professor of Surgery. General Surgeon. Chief of the Division of General Surgery and Associated Chairman, Department of Surgery Creighton University School of Medicine, Omaha, Nebraska, USA. Former President of the American Hernia Society. Former President of the Society of Laparoendoscopic Surgeons. Member of Committee on emerging technology for the American College of Surgeons. 111 original articles in peer-reviewed journals. Six books. 77 book chapters. Seven editorials. More than 400 scientific lectures. Dr. René Fortelny, MD. Univ.-Lector. Chief Resident, 2nd Department of Surgery, Wilhelminenspital, Vienna, Austria. General, visceral and abdominal wall surgeon, Head of the Hernia Center at the Wilhelminenspital, Head of the Experimental Hernia Group at the Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Austria, Vienna. Former President of the Austrian Society for Minimal Invasive Surgery. President elect of the Austrian Hernia Society. 22 publications in peer-reviewed journals. 45 scientific lectures. 25 live demonstrations in hernia repair. Dr. Uwe Klinge, MD. General and Visceral Surgeon. Principal Investigator of the Surgical Department, University of Aachen, and Institute for Applied Medical Engineering AME Helmholtz. Special fields of research: Biocompatibility of meshes. Visualization of meshes. Wound healing. 163 publications cited in PubMed, 53 book chapters; 127 invited lectures. Esther Kuhry, MD, PhD. General Surgeon. St. Olavs Hospital, Trondheim, Norway. Advisor for the Research and Development department. Member of the Cochrane Colorectal Cancer Group. 12 papers in peer-reviewed journals. More than 30 scientific lectures. Prof. Ferdinand Köckerling, MD. Professor of Surgery. Chairman of the Department of Surgery and Center of Minimally Invasive Surgery at the Vivantes Hospital in Berlin, Teaching Hospital of Charité Medical School. Former President of the German Society for Minimally Invasive Surgery. Former President of the German Society for General and Visceral Surgery. Former Congress President of the German Hernia Society. Editorial Board: Surgical Endoscopy; Langenbeck’s Archives of Surgery. 173 papers cited in PubMed. More than 400 presentations in national and international conferences. Davide Lomanto, MD, PhD, FAMS. Associate Professor, Senior Consultant, Director of the Minimally Invasive Surgical Center; Director of the KTP Advanced Surgical Training Center; YYL School of Medicine, National University of Singapore. President of Asia–Pacific Hernia Society. General Secretary of the Asia Pacific Bariatric Surgery Society. Editorial Board: Asian Journal of Laparo-Endoscopic Surgery. Chinese Journal of Hernia and Abdominal Wall Surgery. 85 original articles in peer-reviewed journals; 14 book chapters; 3 books; 184 scientific lectures. Instructor/mentor in 113 live surgery workshops. Prof. Mahesh Chandra Misra, MD. Head of the Department of Surgical Disciplines and Chief; J P N Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India. General, Visceral, and Trauma Surgeon. 70 papers in peer-reviewed journals; 50 scientific lectures; 25 live surgery demonstrations. Salvador Morales-Conde, MD. Chief of the Advanced Laparoscopic Unit of the University Hospital “Virgen del Rocío” (Sevilla, Spain). Head of the General, Digestive and Laparoscopic Surgery Unit of the USP-”Sagrado Corazón” Clinic (Sevilla, Spain). Associate Professor of the University of Sevilla (Spain). Director of the National program of training on Laparoscopic Surgery of the Spanish Association of Surgery. President of the Spanish Society of Abdominal Wall Surgery. Secretary of the Spanish Society of Endoscopic Surgery. Member of the Board of European Hernia Society. Authors of several papers and chapters of books and of the book entitled, Laparoscopic Ventral Hernia Repair. Agneta Montgomery, MD, PhD. Associated Professor. Head of the Laparoscopy and Abdominal Wall Reconstruction Section. Department of Surgery, University Hospital of Malmö, Sweden. Former President of the Swedish Society of Laparoscopic Surgery. Secretary of the Swedish Surgical Society. Former President of the European Society for Surgical Research. Editorial Board: British Journal of Surgery, Scandinavian Journal of Surgery. Hernia. 42 original articles in peer-reviewed journals; 10 book chapters; 70 invited scientific lectures; 13 arrangements of symposia. Prof. Jacob Rosenberg, MD, D.Sc., FRCS, FACS. Professor, Chief Surgeon, Department of Surgery D, Herlev Hospital, University of Copenhagen. Chief Editor: Ugeskrift for Laeger and Danish Medical Bulletin. 264 articles in peer-reviewed journals; 28 editorials; 44 book chapters; 7 textbooks; 190 scientific lectures; taught 133 postgraduate courses. President of the Danish National Hernia Database. Priv. Doz. Dr. Stefan Sauerland, MD, MPH. Head of the Department of Non-Drug Interventions, Institute for Quality and Efficiency in Healthcare, Cologne, Germany. Speciality: development of evidence-based methodology in Germany. Coordination of various clinical trials and clinical practice guidelines. More than 110 original articles in peer-reviewed journals and more than 100 scientific lectures. 2005 Cochrane Prize. Dr. Christine Schug-Paß, MD. General Surgeon. Department for Surgery. Center for Minimally Invasive Surgery. Vivantes Klinikum Spandau, Berlin, Germany. 18 original articles in peer-reviewed journals; 26 book contributions; 70 scientific lectures. Kirpal Singh, MD. General Surgery with Advanced Laparoscopy & Endoscopy, St. Vincent Hospital, Indianapolis, Indiana, USA. Fellow of Maurice Arregui 2002-2004. One paper in a peer-reviewed journal. Michael Timoney, MD. Attending Surgeon/Director of Quality Assurance, Lutherian Medical Center, Brooklyn, New York, USA. Five papers and abstracts in peer-reviewed journals and one correspondence in New England Journal of Medicine. Priv. Doz. Dr. Dirk Weyhe, MD, PhD. General and Visceral Surgeon, Head of the Department of Surgery, Pius Hospital Oldenburg, Germany. Speciality: biocompatibility of synthetic materials. 50 publications in peer-reviewed journals; 2 book contributions; 99 scientific lectures. In summary, the guidelines have been developed by leading hernia surgeons from Europe, America, and Asia, working in high spirits and in an atmosphere of deep friendship. The result is a truly global achievement pointing to the future. We thank all of the contributors for their tireless efforts and their unwavering dedication to hernia surgery without any remuneration or compensation even for traveling expenses. If you do a PubMed literature research using the term “hernia surgery,” you will find 29,939 publications. The Guidelines should assist the surgeon in his clinical practice to make the right decision and to improve his technical performance. For validation and agreement, every expert received at least twice all of the chapters written by the other authors. All comments and critics were seriously discussed with the respective author and, if necessary, the statements and recommendations were revised accordingly. In addition, the steering committee carefully reviewed every paper. The Guidelines are valid until December 2013. The update meeting will be organized in due time by the first and last authors. Chapter 1: Perioperative management: what is the evidence for antibiotic and thromboembolic prophylaxis in laparoscopic inguinal hernia surgery? Agneta Montgomery Department of Surgery, University Hospital Skåne, Malmö, Sweden Is antibiotic prophylaxis routinely indicated for an elective laparoscopic inguinal hernia operation? Is thromboembolic prophylaxis routinely indicated for an elective laparoscopic inguinal hernia operation? Search terms: “Antibiotic prophylaxis” AND “laparoscopy” AND “inguinal hernia”; “Antibiotic prophylaxis” AND “TEP” AND “TAPP”; “Antibiotic prophylaxis” AND “randomized studies” AND “inguinal hernia”; “Thromboembolic prophylaxis” AND “laparoscopy” AND “inguinal hernia”; “Thromboembolic prophylaxis” AND “TEP” AND “TAPP”; “Thromboembolic prophylaxis” AND “randomized studies” AND “inguinal hernia.” Statements Level 5 There is insufficient evidence for routine antibiotic prophylaxis in laparoscopic hernia surgery. Level 5 There is insufficient evidence for routine thromboembolic prophylaxis in laparoscopic hernia surgery. Recommendations Grade D Antibiotic prophylaxis for elective laparoscopic inguinal hernia repair cannot be universally recommended. Grade D It is recommended that antibiotic prophylaxis should be considered in the presence of risk factors for wound and mesh infection based on patient (advanced age, corticosteroid usage, immunosuppressive conditions and therapy, obesity, diabetes, and malignancy) or surgical complications (contamination, long operation time, drainage, urinary catheter). Grade D It is recommended that thromboembolic prophylaxis is given according to usual routines in patients with risk factors. Antibiotic prophylaxis Antibiotic prophylaxis in inguinal hernia surgery is controversial. The overall infection rate is low, with a mean value of 1–4% [1–4]. An infectious rate 75 years, obesity, and urinary catheter were heavy risk factors for global infectious complications in one study . Other known risk factors for infectious complications are hernia recurrence, diabetes, immunosuppressant, corticosteroid usage, and malignancy. RCT studies as well as systematic reviews and meta-analyses on antibiotic prophylaxis versus placebo were identified. To analyze the wound infection rate in a large population, the Swedish National Hernia register was searched for the years 1992–2006 . The five largest RCTs between open and laparoscopic hernia repair, having wound infection as a secondary endpoint, also were analyzed [6–10], as well as large case series reporting on antibiotic prophylaxis and infectious complications. A total of five systematic reviews or meta-analyses comparing antibiotic prophylaxis versus placebo were identified. Sanchez-Manuel and Seco-Gil  reported in the Cochrane Database system in 2004 and updated the results in 2007 . Three different systematic reviews and meta-analyses were performed in 2005, 2006, and 2007 [3, 12, 13]. Almost the same studies are referred to in these publications adding some new references each time. A total of 12 randomized studies are presented in the latest Cochrane Publication , involving only open surgery. Until now, a total of 14 RCTs comparing antibiotic prophylaxis versus placebo in inguinal hernia surgery were identified, of which there was only 1 about laparoscopic repair and the remaining 13 were about open repair (Table 1). Table 1 RCT comparing prophylaxis versus nonprophylaxis antibiotics in inguinal hernia surgery Author Prophylaxis Total n Infection prophy laxis (%) Nonprophylaxis Total n Infected nonprophylaxis (%) RRA CI 95% NNT Level of evidence Open hernia surgery included in Cochrane Evans et al. (1973)  48 2.1 49 4.1 2 (−4.9, 8.9) 50 3b Anderson et al. (1980)  137 3.6 150 4 0.4 (−4.1, 4.7) 285 2b Platt et al. (1990)  301 1.3 311 1.9 0.6 (−1.4, 2.6) 167 1b Lazhortes et al. (1992)  155 0 153 4.6 4.6 (1.2, 7.9) 22 2b Taylor et al. (1997)  283 8.8 280 8.9 0.1 (−4.6, 4.7) 1057 1b Morales et al. (2000)  237 1.7 287 2.1 0.4 (−1.9, 2.7) 248 1b Yerdel et al. (2001)  136 0.7 133 9 8.3 (3.2, 13.4) 12 2b Oteiza et al. (2004)  124 0.8 123 0 −0.8 (−2.4, 0.7) 124 2b Aufenacker et al. (2004)  475 1.7 472 1.9 0.2 (−1.5, 1.9) 449 1b Celdan et al. (2004)  50 0 49 8.1 8.2 (0.5, 15.8) 12 2b Pessaux et al. (2005)  2008 3.4 394 5.1 1.7 (−0.6, 4) 59 2b Perez et al. (2005)  174 1.7 176 3.4 1.7 (−1.6, 5) 59 2b Total 4,128 2.9 2577 3.9 1.1 (0.2, 2) 92 Laparoscopic hernia surgery not included in Cochrane Schwetling and Bärlehner (1998)  40 0 40 0 ns 2b Open hernia surgery not included in Cochrane Tzovaras et al. (2007)  193 2.6 193 4.4 p = 0.4 2b The endoscopic RCT by Schwetling and Bärlehner  has an incorrect randomization, lacks a definition of wound infection, and is heavily underpowered with only 40 patients in each arm. It does not allow any conclusions to be made and is not included in the Cochrane review. In the remaining studies on open hernia repair, a total of 4,128 patients are included in the latest report from the Cochrane database by Sanchez-Manuel and Seco-Gil . The wound infection rate was 2.9% in the prophylaxis group and 3.9% in the nonprophylaxis group with no statistical difference. There is a huge variation in infection rate between the studies both in the prophylaxis group (0–8.8%) and nonprophylaxis group (0–8.9%). A subgroup analysis between no mesh and mesh was performed. In the no-mesh group, an infection rate of 3.5% was seen in the prophylaxis and 4.9% in the placebo with no statistical difference. In the mesh group, the infection rate was 1.4% in the prophylaxis and 2.9% in the placebo, also with no statistical difference. Only one further randomized, controlled study on open hernia surgery has been presented after the latest Cochrane report  (Table 1). Wound infection is registered as a secondary endpoint in large RCTs on laparoscopic versus open operation, but only two of five mention antibiotic prophylaxis (Table 2). The infection rate varies between 0–2.8% in the laparoscopic group and 0.7–3.1% in the open group. There are significantly more infections reported in the open group in one study, whereas all other studies show no difference between groups, including the two studies that report the administration of antibiotics. Table 2 RCT comparing laparoscopic versus open inguinal hernia surgery with infectious complications as a secondary endpoint Study Name, country Antibiotic prophylaxis Total Lap group Lap infect. (%) Open group Open infect. (%) n Liem et al. (1997)  Coala, Netherlands ? 994 487 TEP 0 507 Optional 1.2 0.03 MRC 1999  MRC, UK ? 928 468 TEP, TAPP 2.8 460 Optional 3.1 NS Berndsen et al. (2002)  SMIL I, Sweden No 1,042 518 TAPP 0.8 524 Shouldice 0.8 NS Neumayer et al. (2004)  AV, USA ? 1,983 989 TEP, TAPP 1 994 Lichtenstein 1.4 NS Eklund et al. (2006)  SMIL II, Sweden No lap yes open 1,371 665 TEP 1.4 706 Lichtenstein 0.7 0.21 Total 6,318 3,127 1.2 3,191 1.3 ? = Whether antibiotic prophylaxis was given is not reported NS not significant, Lap laparoscopic, infect infection, TAPP laparoscopic transabdominal preperitoneal repair, TEP laparoscopic totally extraperitoneal repair Five TAPP case series, including more than 1,000 patients each, reported on wound and/or mesh infections [27–31]. Four studies are from the same institution. Antibiotic prophylaxis was given to all patients and commented about in only one study . No large TEP series was identified. Schmedt et al.  reported 0.07% infections in 4188 unilateral TAPP procedures and 0% in 1,336 bilateral procedures. Kapiris et al.  reported 0.11% mesh infections in 3,017 patients, and Leibl et al.  reported 3 cases (0.001%) in 2,700 patients. Bittner et al.  reported 0.1% mesh infections and 0% wound infections in 8,050 TAPP procedures in a total of 6,479 patients. The Swedish National Inguinal Hernia Register recorded the wound infections between 1992 and 2006. The incidence was 1.4% in 28,220 patients recorded to have received antibiotic prophylaxis. The infection rate also was 1.4% in the nonprophylactic group, consisting of 104,354 patients . There is no specific analysis on the laparoscopic patients representing approximately 8% of the patients who underwent surgery. Pessaux et al.  has converted predictive risk factors for infection, such as age older than 75 years, obesity, and urinary catheter, into a global infection complication score. Low-risk patients had an infection rate of 2.7% and high-risk patients of 14.3% (p 0.0001) and incidence of trocar hernias (cutting trocar 1.27 vs. 0.037% conical trocar, p > 0.0001) . The equal effect on incisional pain of both trocar types found in patients after laparoscopic cholecystectomy is no reason to continue to cutting trocars . In TAPP, three trocars are usually placed at the umbilical level (optic and two working ports); all working ports are inserted under direct vision. The parietal, intraabdominal, and retroperitoneal vascular injuries are preventable with good anatomical orientation and cautious pressure-controlled trocar insertion. The optimal trocar positioning respects the rules of triangulation to facilitate and improve the workflow ergonomics. Consider the proximity of bony structures as potential inhibitors of instrumentation freedom. Assessment of defect, contralateral site, exploration of abdominal cavity Is clinical examination of hernias efficient enough? What is the role of TAPP and other techniques in reliable assessment? Statements Level 1B A significant proportion of incidental defects will progress to a symptomatic hernia if left untreated. Level 2B Clinical examination is accurate only in 75–89% of patients. The sensitivity of ultrasound is clearly higher than a mere physical examination. Level 2B TAPP enables rapid evaluation of the “contralateral groin” (clinically unsuspected) hernia. Level 2C TAPP is beneficial in avoiding unnecessary explorations and repairs of the contralateral side. Recommendations Grade A The patient with unilateral hernia should be informed about the possibility of having undiagnosed contralateral hernia. The patient should be informed about advantages and disadvantages of simultaneous repair. Grade B In case of clinical uncertainty diagnosing the hernia, an ultrasound examination should be done. If the patient agrees, the incidental contralateral defect should be repaired simultaneously. Grade D In case of diagnostic uncertainty (inguinal pain, inconclusive clinical evaluation, recurrence, occult hernia) despite extensive use of the diagnostic tools—ultrasound, CT scan, MRT—TAPP may be the approach of choice. Grade D When at laparoscopy no hernia opening is visible in patients with strong clinical suspicion of hernia, a preperitoneal exploration is indicated. The accuracy of a clinical groin examination is limited. The incidence of occult contralateral hernia found at the time of unilateral hernia repair using TAPP or TEP is up to 25% [23, 24]. For definitive proof of the presence of a hernia, the sensitivity of ultrasound is clearly higher than a mere physical examination. The final and definitive classification of hernias can only be made intraoperatively; at best, the results of an ultrasound examination can help to orientate the surgeon. The TAPP enables rapid assessment . In conventional hernia surgery or with the total extraperitoneal (TEP) method, this kind of evaluation is impossible or at least problematic. In case of a missing hernia sac, most cord lipomas can be visualized when external pressure is applied over the groin. When no hernia is found in patients with strong hernia suspicion (positive clinical examination, positive ultrasound finding), the preperitoneal exploration is still indicated to rule out other pathologies of inguinal canal or preperitoneal lipomas in the femoral canal. A significant proportion of incidental defects will progress to a symptomatic hernia if left untreated (28% within 15 months). Therefore, incidental hernias should be simultaneously repaired if the patient has agreed ; 11% of clinically unrecognized hernias were repaired at the time of surgery. TAPP herniorrhaphy is beneficial to avoid unnecessary explorations and allow timely repairs in patients with occult inguinal hernias [25, 42]. Although the reported incidence of chronic pain after TAPP repair is very low, the simultaneous repair of the healthy contralateral groin “in advance” is not justified unless a “significant collagen deficiency” is suspected. Anatomical landmarks, peritoneal incision, extent of dissection Statements Level 5 There is not enough data available on the influence of the particular steps of the surgical technique and the individual performance on the outcome. Level 5 Taking down adhesion between omentum or bowel to the peritoneum of groin or to the hernia sac is mostly not necessary. It carries additional risk of intestinal injury. Recommendations Grade D A meticulous operative technique and the adequate extent of preperitoneal anatomical dissection (whole pelvic floor) belong to the most important key points of TAPP repair. Grade D Reduction of the hernia sac inclusive adherent content if excising should be done en bloc. In the majority of cases, the anatomical points of primary orientation are visible or demonstrable by external palpation: the medial umbilical ligament (MUL), the lower epigastric vessels (the lateral umbilical ligament), the deep (inner) inguinal ring, the anterior superior iliac spine (ASIS), and the spermatic structures (vas deferens and spermatic vessels) or the round ligament. The other important structures (secondary orientation) become visible during the preperitoneal dissection: the ileopubic tract, the symphysis pubis, Cooper’s ligament, and the femoral canal. In case of local omental or intestinal adhesions to the peritoneum of the groin, it is not recommended to perform adhesiolysis in general, unless it obstructs the overview. In sliding hernias or even irreducible hernias, neither adhesiolysis nor reduction is mandatory, but the straightforward preperitoneal dissection should be performed. This facilitates the mobilization of hernia content within the sac and helps to avoid intestinal injury. In strangulated hernias, the preperitoneal dissection allows to visualize the safe position of a relaxing incision of the hernia ring if necessary [1, 4]. Surgical strategy No studies have compared different positions of the patient and the operating table or the positioning of the surgeons. However, there is a general agreement that the patient is kept in the supine position on the operating table, which is in head-down position during the operation and slightly (approximately 15°) turned toward the surgeon [1, 4]. The operating surgeon and the camera assistant stay on opposite sides of the hernia. The peritoneal incision is placed 3–4 cm above all possible defects from ASIS to MUL (not vice versa ER, PE), which does not have to be transected. If more space is needed, a cranial extension of the peritoneal incision parallel to MUL may be helpful. A complete anatomical dissection of the whole pelvic floor is necessary for a flat and wrinkle-free placement of the mesh. The extent of dissection reaches medially 1–2 cm beyond the symphysis pubis to the contralateral side, cranially 3–4 cm above the transversalis arch or any direct defect, laterally to ASIS, and caudally minimally 4–5 cm below the ileopubic tract at the level of psoas muscle and 2–3 cm below the Cooper’s ligament at the level of superior arch of the pubic bone. The resulting preperitoneal space has to accommodate a mesh of adequate size (at least 10 × 15 cm2) (PE). The level of the dissection plane within the avascular “spin-web” space between the internal and external layer of peritoneum is crucial. The objective is to retract all peritoneal sack and corresponding pre-, extra-, and retroperitoneal fat tissue from the hernia orifices down to the middle of psoas muscle (=parietalization) [1, 3, 4, 7]. The preservation of the spermatic fascia and of the lumbar fascia protects the fragile parietal structures (vas deferens, vessels and the nerves) . Indirect hernias Statements Level 2C Cord lipomas or lipomas in the femoral canal may imitate primary hernia, hernia recurrence, or become symptomatic in later course. Level 4 Complete reduction of the hernia sac does not increase the incidence of sero-hematomas if careful dissection and control of hemostasis are done. Level 5 Complete reduction of the hernia sac may eliminate the occurrence of chronic seroma/“pseudo-hydrocele.” Recommendations Grade B Lipomas of spermatic cord/round ligament and the preperitoneal lipomas of direct and femoral sacs should be removed. Grade D In case of unclear anatomy, first identify spermatic vessels. Grade D If dense adhesions to the cord structures are present in a long hernia sac, the sac may be exceptionally transected at the level of inner inguinal ring to prevent injury. Large and/or deep indirect sacs may prolong the operating time, but complete retraction is possible in almost every case. Delicate dissection and ongoing control of hemostasis do not increase the incidence of scrotal hematoseromas  but eliminate the formation of chronic seroma/pseudo-hydrocele. The transection of a difficult indirect sac was suggested to prevent possible damage to the spermatic cord and decrease the incidence of scrotal hematomas. Bittner et al.  reported low rates of orchitis (0.1%) and testicular atrophy (0.05%) despite nearly always complete reduction of the sack. In difficult conditions, in the presence of large and deep sacs, after temporary strangulations or in complicated recurrences, the following strategy is recommended: identify the spermatic vessels far latero-caudally first before starting the dissection along the vessels towards the inguinal canal and to the top of the indirect sac. In this manner, damage to the spermatic vessels can be safely prevented [1, 4]. Quite often, substantial funicular lipomas or pre-/or retroperitoneal fat prolapse into the enlarged hernia orifices ring [45–48]. They should be retracted and eventually resected, because they may become symptomatic or mimic a recurrent hernia . An overlooked lipoma is one of the known reasons for “recurrence” . Although the published data provide low evidence, the search for and exclusion of such masses is integral part of the endoscopic hernia repair [51, 52]. Direct hernias Statements Level 2B The incidence of seromas in direct hernias can be significantly reduced when the lax transversalis fascia is inverted. Level 2C Seroma is a common early postoperative minor complication in endoscopic preperitoneal hernia repair. Recommendations Grade B In voluminous direct hernias, the extended transversalis fascia should be inverted. A prospective nonrandomized study demonstrates significantly lower incidence of postoperative seromas in the group of patients with direct hernias and transversalis fascia inversion, without increase of postoperative pain despite the use of invasive fixation with tacks to the Cooper’s ligament . In some expert reports, fixation with sutures is recommended as a less expensive alternative. A cautious use of superficial electrocoagulation to obliterate blood, and lymphatic vessels, also has been suggested to reduce seroma formation [1, 4]. Mesh choice, mesh size, mesh slit, mesh fixation The mesh issues (type, size, slited/nonslited, and fixation) are technical key points of paramount importance. The details will be analyzed and discussed in another chapter. Peritoneal closure Statements Level 3 Incomplete peritoneal closure or its breakdown in endoscopic preperitoneal hernia repair increases the risk of bowel obstruction. Level 3 TAPP procedure presents a higher statistical risk of small-bowel obstruction than TEP. Level 5 The most appropriate peritoneal closure is achieved by running absorbable suture. Level 5 Running suture seems to cause less pain compared with clip/tack closure. Level 5 The closure of entrance of indirect sacs may reduce the risk of internal hernia with consecutive incarceration, strangulation, or small-bowel obstruction. Recommendations Grade C A thorough closure of peritoneal incision or peritoneal tears should be done. Grade D The peritoneal closure can be accomplished by running suture. The bowel obstruction can develop due to adhesions between omentum or epiploic appendices and suture line, between the mesh and the intestines, e.g., by inadequate closure of a peritoneal lesion [54–56]. The peritoneal opening must be thoroughly closed to prevent contact of viscera with the prosthetic mesh material and to reduce the risk of bowel obstruction. The closure can be achieved with staples, tacks, running suture, or glue. These last two methods are more time-consuming but less painful [1, 4] (see Chap. 9). Rare cases of bowel obstruction in port-site hernias also have been described, especially after TAPP. The reduction of intra-abdominal pressure (e.g., 8 mmHg or less) facilitates the peritoneal closure during the running suture, especially in difficult cases [1, 4]. Several anecdotic reports on small-bowel obstruction both in TAPP  and TEP repairs have been published [57, 58]. The data from Swedish National Inguinal Hernia Register show higher incidence of late postoperative bowel obstruction after TAPP than after TEP . Theoretically, the deep indirect sacs could cause internal hernia. Therefore, the author closes the internal orifice of the sac to eliminate the incarceration risk (author’s personal experience). Port-site closure Statements Level 3 Use of 10-mm trocars or larger may predispose to hernias, especially in the umbilical region or in the oblique abdominal wall. Recommendations Grade C Trocar sites with fascial defects of 10 mm or larger can be closed. Port-site hernia is a late postoperative complication predominantly reported in TAPP repair. Although, according to general opinion, only 10 mm and bigger trocar site defects should be closed, the development of incisional hernia with consequences was described even with 3–5-mm trocars [59–65]. A review of 63 reports (24 case reports, 27 original articles, 7 technical notes, and 5 review articles) was published in 2004 . The evidence level of these reports varies from 1 to 3. Recommendation B concerns the closure of trocars of 10 mm or bigger. A difference should be made between the periumbilical closure and the closure of the working ports. Again, it should be differentiated according the defects through the rectus muscle and through the weaker oblique abdominal wall. A pre-existent umbilical hernia/weakness must be treated like a primary hernia (author’s personal experience). It is the author’s opinion that it is important to close the peritoneum in lateral working ports ≥10 mm, because trocar hernias do not occur in TEP (peritoneum under working ports remains intact) (PE). Pain control Statements Level 5 Additional use of local anaesthetic positively influences postoperative pain in TEP and TAPP. Infiltration of trocar wounds with long-acting local anaesthetic in TAPP improves patient’s well-being and accelerates return to ambulation. Recommendations Grade D To improve postoperative pain control, trocar wounds can be infiltrated by local anesthetics. Efficient pain control after hernia repair is a pillar of success. A significant reduction of postoperative pain through preemptive use of Bupivacaine was described in TEP . Such effect was not reported in TAPP yet, although routine infiltration of the wound after hernia repair provides extra pain control and limits the use of analgesics. Additional use of local anesthetics positively influences postoperative pain in TAPP. Infiltration of trocar wounds with long-acting local anesthetic in TAPP improves patient’s well-being and accelerates return to ambulation (PE). Conclusion on technical key points in TAPP repair The multitude of data published on this subject presents different levels of evidence, but particular technical key points are well investigated [68, 69]. Some expert opinions lack supporting data, but some steps of the TAPP technique are clearly supported by strong levels of evidence. The grade of recommendations varies from A to D. The proven technical key points should become the pillars of the standardized TAPP repair, transferred to the wide surgical community and emphasized in the teaching and learning environment to guarantee the best possible outcomes. References (in parentheses graduation of evidence) Bittner R, Schmedt CG, Leibl BJ (2003) Transabdominal pre-peritoneal approach in LeBlanc KA. Laparoscopic hernia surgery. London: Arnold Publisher; pp 54–64. (2C) Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ (2002) Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg 89:1062–1066. (2C) Bittner R, Kraft K, Schmedt CG, Leibl BJ (2000) Technik der laparoskopischen Hernioplastik (TAPP). Chir Gastroenterol 16:98–103. (4) Bittner R, Leibl BJ, Ulrich M (2006) Chirurgie der Leistenhernie, Karger, Freiburg. (2C) Leibl BJ, Kraft K, Schmedt CG, Bittner R (2001) Access techniques for endoscopic surgery-types of trocars, ports and cannulae—an overview. 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(1A) Chapter 3: Technical key points: total extraperitoneal patch plasty (TEP) repair P. Chowbey, F. Köckerling, D. Lomanto Search terms: inguinal hernia, femoral hernia, total extraperitoneal repair (TEP), preperitoneal access, space creation, needlescopic, ports, peritoneal tears, complications, mesh, fixation. Preoperative preparations Is it necessary to empty the urinary bladder before TEP? Which is the best way of emptying the urinary bladder: catheterization or voiding? Statements and recommendations are not different to TAPP. See Chap. 2 (Kukleta) and Chap. 11 (Fitzgibbons), and References 1–7. Positioning of patient and surgeons Recommendation Level 5 The patient is kept in the supine position. Level 5 The operating surgeon and the camera assistant stay on opposite sides of the hernias. No studies have compared different positions of the patient and the operating table or the positioning of the surgeons. However, there is a general agreement that the patient is kept in the supine position [8, 9] on the operating table, which is in head-down position during the operation and slightly (approximately 15°) turned toward the surgeon. The operating surgeon and the camera assistant stay on opposite sides of the hernias . Preperitoneal access What is the most popular mode of accessing the preperitoneal space? Statements Level 4 Direct open access is a simple and reproducible technique for accessing the preperitoneal space. Access by transperitoneal visualization is an alternative but is associated with the risks of entering the peritoneal cavity. Suprapubic Veress needle technique also is used by few surgeons. Recommendations Grade D Direct access with the Hasson trocar via a 1–2-cm subumbilical incision on the side of hernia and opening of the rectus sheath, enlargement of the space between the rectus muscle and the posterior sheath. Direct access with Hassan trocar has been popularized by many and is used by Ferzli et al. , McKernan and Laws , Chowbey , Garg et al. , and Köckerling . The suprapubic Veress needle technique  requires the placement of Veress needle in the space of Retzius followed by carbon dioxide insufflation and direct trocar placement. In this method, it is difficult to place the Veress needle correctly and the working space is initially narrow. The transperitoneal visualization technique of Philip [14, 15] requires creation of pneumoperitoneum and subsequently a preperitoneal blister is raised using 0.5% Bupivacaine followed by direct trocar placement in the preperitoneal space. This also has been used by Arregui and Young . The disadvantage of this technique is the addition of complications inherent to a transperitoneal approach, such as bowel injury and port site hernia. The presence of pneumoperitoneum may compromise the extraperitoneal space. Space creation Which technique of space creation best achieves the required extraperitoneal space? Statements Level 1B Balloon dissection is associated with significantly reduced postoperative pain at 6 h, scrotal edema, and seroma formation compared with telescopic dissection. At 3 months follow-up, balloon dissection did not offer significant advantage over direct telescopic dissection. The use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve. The technique of balloon dissection provides adequate extraperitoneal space creation and is evolving as a method of choice; indigenous balloons contribute to cost-effectiveness. Dissection with the telescope is another frequently used method. Anatomical delineation of inguinal area and dissection in the extraperitoneal space in TEP repair was equally satisfactory in both the balloon dissection and the telescope dissection group. Recommendations Grade A Balloon dissection should be considered for extraperitoneal space creation, especially during the learning period, when it is difficult to find the correct plane in the preperitoneal space. Balloon dissection is the most commonly used method to create extraperitoneal space . There are commercially available balloons [18, 19] as well as low-cost indigenous balloons, such as the ones used by Chowbey  in which two cut fingers stalls of an 8-size glove are applied over a suction-irrigation cannula and tied with silk. Similar techniques and minor variations thereof have been used by different authors [21–24]. A randomized, prospective, multicenter study showed that a dissection balloon made the dissection of preperitoneal space easier and safer, thus reducing operative time, conversion rate, and number of complications . Blunt probe dissection under vision with a 10-mm zero-degree operative scope with a 5-mm working channel was described by Ferzli et al. in 1992 . Direct telescopic dissection has been described by McKernan and used in many centers across the globe . Modifications to the technique of balloon dissection are needed for patients with previous lower abdominal surgery. The balloon is distended much less than in those without previous surgery and away from the scar site to prevent tearing of scar tissues and thereby decreasing the potential for tearing of bowel, bladder, or peritoneum . Furthermore, balloon dissection has a major disadvantage in patients who have a linea alba that extends to the pubic symphysis. In these patients, the balloon will dissect one side of the preperitoneal space posterior to the epigastric vessels and may cause bleeding (Ferzli, personal comment). The role of needlescopic TEP Statements Level 2 B Needlescopic TEP is a safe technique for the repair of inguinal hernia. Postoperative recovery after needlescopic and conventional TEP was similar. Needlescopic TEP conferred a significantly lower pain score upon coughing on the first day after operation. Recommendations Grade C In patients with a low pain threshold, a needlescopic TEP can be performed. In the past, needlescopic TEP was difficult because the instruments were not strong enough to allow sufficient dissection of the hernia sac, especially of the indirect sac; however, new technical developments have eliminated this problem . Ports How does port positioning contribute to the technique of TEP repair? Statements Level 5 The midline ports have the advantage of accessing both sides with equal ease and minimal risk of injuries to the inferior epigastric vessels. All three ports made in the midline at the commencement of the procedure enable bimanual dissection right from the start. Another technique of a 10-mm port at the umbilicus, a 5-mm port a few centimeters lower, and another 5-mm trocar laterally near the anterior–superior iliac spine is the next alternative. Overlapping mesh in the midline is thought to be easier with this technique. Lateral ports, two in number, just lateral to the rectus muscle, used along with a midline camera port are an option. Recommendations Grade D Two alternatives for the trocar placement: two 5-mm working ports in the midline, and in the midway between the camera port and the pubic symphysis. Alternatively, the second working trocar (5 or 10 mm) can be placed after lateral dissection approximately 3–4 cm superior and 1–2 cm anterior to the anterosuperior iliac spine. Lateral working trocars are favored when mesh overlap over the midline is perceived to be difficult. Three ports are required, of which the camera port is constant and is a 10-mm subumbilical port. The two working ports are variable. Both of them may be in the midline as far cephalad as possible from the pubic symphysis. Another option is one midline port below the camera and one lateral port near the anterior superior iliac spine [13, 26]. This port placement gives a better trocar triangulation and makes complete dissection of large lateral hernia sacs easier. Along with the three midline ports, additional ports if required can be placed lateral to the rectus muscle below the linea semicircularis . Caution should be exercised to avoid injury to inferior epigastric vessels during introduction of the lateral trocar . Dissection of preperitoneal space What are the limits of dissection and the landmarks to be visualized? Statements Level 3 The dissection should extend superiorly up to the subumbilical area, inferiorly to the space of Retzius, inferolaterally to the psoas muscle and Bogros space until spina iliaca anterior superior is reached, and medially beyond the midline. The landmarks to be visualized are the pubic bone, Cooper’s ligament, inferior epigastric vessels, cord structures, the myopectineal orifice boundaries, and the fascia over psoas muscle. Posteriorly, the peritoneum is reflected to the point of which the vas turns medially. Level 4 Extensive preperitoneal dissection with complete exposure of the myopectineal orifice of Fruchaud is critical to the success of the laparoscopic inguinal hernia repair. Recommendations Grade B Complete parietalization of the vas deferens and the testicular vessels needs to be performed. Complete dissection of the whole pelvic floor (anatomical) should be done for flat placement of the mesh to cover the entire myopectineal orifice and prevent its folding. Before any dissection is performed, the pubic tubercle, the iliopubic tract, and Cooper’s ligaments must be clearly identified. The complete space medial to the inferior epigastric vessels (Retzius) must be visible, and then the transversus abdominis muscle lateral to the epigastric vessels to the level of anterior superior iliac spine has to be exposed . Wide exposure of preperitoneal space is the key to a good TEP repair . What are the techniques of management of a peritoneal tear during TEP? How can peritoneal tears be prevented and treated? Statements Level 3 The incidence of peritoneal tear is 47%. Techniques for the closure of a peritoneal opening include pretied suture, loop ligation, endoscopic stapling, and endoscopic suturing. To decrease the potential for peritoneal tear, the balloon dissection is modified. Less volume of saline is used for inflation; the balloon is sited away from the scar. Careful dissection in close proximity to the vas deferens and adhesions, in addition to cautious use of traction and counter traction, associated with prudent application of sharp dissection with endo-scissors to divide adhesions can help to prevent peritoneal laceration. Recommendations Grade D It is recommended that peritoneal tears be closed whenever feasible to prevent adhesions. Peritoneal tear is the most common reason for conversion and predisposes patients to small-bowel adhesions and internal herniation. The mesh is no longer securely buttressed between the abdominal wall and retroperitoneum by intra-abdominal pressure and becomes susceptible to migration when not stapled. Hence, closure of the defect is preferred . Difficulty in reaching the pubis by the balloon dissector is associated with an increased risk of peritoneal tear . In a randomized multicentric trial, a 24% incidence of peritoneal tears was found, but loss of pneumopreperitoneum occurred only in 7%, which required switching to another technique . In a study of 107 consecutive TEP repairs , it was found that no peritoneal tear was noticed in two patients with previous laparotomy scars and 17 patients with previous hernia repair scars after balloon dissection of preperitoneal space. However, minor peritoneal tears resulted in a few cases during dissection and retraction of the hernial sac. None of the peritoneal defects in these few cases were closed. Shpitz et al. (2004) found no perioperative or postoperative complications related to these tears . In a prospective study of 400 patients  with a total of 588 inguinal hernias, tiny peritoneal defects occurred in 13% of the hernias, which were closed in most cases with a running endoclip suture. Various methods of closure include loop ligation, pretied suture, endoscopic stapling, and endoscopic suturing . How best can injury to the urinary bladder and epigastric vessels be avoided? Urinary bladder injury (see Chap. 11, Fitzgibbons) Statements Level 3 In patients who have previously undergone lower abdominal surgery or suprapubic catheterization, injury to the bladder is the most common major complication of TEP (0.06–0.3%). Recognized intraoperatively bladder injuries may be managed endoscopically. Recommendations Grade C Utmost caution to prevent a bladder injury is necessary in a patient with previous lower abdominal surgery and a high index of suspicion to recognize one intraoperatively and manage if it were to occur. Injury to the bladder was seen in 8 of 3,868 patients who underwent surgery during a 7.5-year period, the majority of whom had previously undergone suprapubic catheterization [13, 32]. Inferior epigastric artery injury Statements Level 3 Plane should be developed with inferior epigastric vessels anteriorly and the cord structures posteriorly. In 2.75%, bleeding from epigastric branches, vessels on the pubic bone or testicular vessels can occur. Level 4 Inferior epigastric vessels were ligated in 3%, because they blocked the view of the surgeon. Inferior epigastric vessel injury occurred in 0.4% of patients during trocar insertion. Recommendations Grade C Dissection should be performed in the plane posterior to the inferior epigastric vessels, because they are prone to injury when they drop down and also obstruct the view of the surgeon. Correct plane of dissection is important to prevent inferior epigastric vessel injury [7, 27, 32]. Bleeding is usually controlled endoscopically . Dissection of hernia sacs Direct sac How should a large direct sac be handled? Statements Level 2B In large direct hernias, inversion and fixation of the extended fascia transversalis to Cooper’s ligament may reduce the frequency of occurrence of serohematoma. Level 3 Direct Hernias are already largely reduced by inflation of the balloon, through the wall of which the whitish enlarged fascia transversalis can be seen overlapping the Cooper’s ligament. Seroma formation seems to be more common after repair of direct hernia with significantly enlarged transversalis fascia. In an incarcerated hernia, the opening of the defect may be enlarged to allow safe dissection of its contents. A releasing incision is made of the anteromedial aspect of the defect to avoid injury to epigastric or iliac vessels. Recommendations Grade B The direct sac should be inverted and anchored to Cooper’s ligament to decrease the risk of seroma and external hematoma formation. Grade D In incarcerated direct hernias, the opening of the defect may be enlarged or an anteromedial releasing incision may be used. The direct hernial sac is the first structure to be reduced starting from midline laterally, medial to the inferior epigastric vessels. The fundus was separated from the redundant fascia transversalis, which gives the appearance of a reverse sac and then pulled down . The defect may be enlarged or a releasing incision given when the hernia is incarcerated . A prospective, nonrandomized study demonstrates significantly lower incidence of postoperative seromas in the group of patients with direct hernias and transversalis fascia inversion, without increase of postoperative pain despite the use of invasive fixation with tacks to the Cooper’s ligament . In some expert reports, fixation with sutures is recommended as a less expensive alternative. Indirect sac How should a large indirect sac be handled? Statements Level 4 Dissection of the indirect hernial sac, for the most part blunt, is performed under exposure of the spermatic cord/round ligament and all inguino-femoral hernial orifices. Complete dissection of large indirect sacs may carry the risk of an injury of the cord structures or may disturb blood circulation to the testis. Recommendations Grade C A large indirect sac may be ligated proximally and divided distally. In a case of indirect hernia, lateral to the inferior epigastric vessels, the peritoneal sac is dissected away from the cord structures, both medially and laterally until it is separated completely and then dealt with appropriately . At times, a long indirect sac cannot be completely reduced from the deep inguinal ring and is divided, the peritoneal side being ligated with a laparoscopic suture [19, 34] (see Chap. 11 Fitzgibbons). Femoral hernia Should occult femoral hernia be looked for and treated? Statements Level 2C Women have a higher risk of recurrence after an open inguinal hernia repair operation due to a higher occurrence of overlooked femoral hernia at primary operation. Recommendations Grade D A preperitoneal endoscopic approach should be considered in female hernia repair. The high frequency of femoral recurrence after inguinal herniorrhaphy in women argues for the use of endoscopic repair covering both inguinal and femoral orifices simultaneously . Contralateral dissection: how far? Should occult contralateral hernias always be looked for? Statements Level 3 The incidence of incipient unsuspected contralateral hernia is 11.2–20%. Laparoscopic hernia repair (TAPP) has a major advantage of allowing the surgeon to explore the site contralateral to the clinically diagnosed hernia without any additional dissection steps. In TEP, the contralateral medial space can be explored easily, but the exploration of the deep inguinal ring may be difficult. Recommendations Grade D The systematic exploration of the contralateral side using the TEP technique is controversial. Further studies are needed. Hertz and Holcomb performed a laparoscopic transabdominal exploration before performing a TEP inguinal hernia repair and reported an incidence of incipient contralateral hernias as high as 20%. Laparoscopic TAPP repair allows easy identification of the hernia sacs without any need to dissect the spermatic cord. However, it is accompanied by the risk of visceral adhesions to the mesh and the peritoneal dissection site. TEP eliminates the need to penetrate the abdominal cavity. Skeletonization of the cord to detect an asymptomatic hernia is not necessary and avoiding excessive dissection limits the potential for injuries to vas deferens and spermatic vessel . Tenting of the peritoneum toward the internal ring and inability to visualize the vas warrants further dissection of the cord. The advantage of contralateral exploration is that an unsuspected contralateral inguinal hernia can be diagnosed at the time of initial surgery, and if treated, the patient can avoid reoperation, exposure to a second anesthesia, another period of work loss, and containment of costs to the healthcare system. The disadvantages would be the violation of a virgin space, difficulty in the event of a requirement for surgery at a later date, and the additional time and morbidity associated with the procedure. In the light of this observation, another question arises “once dissected, is there a need or advantage in placing a contralateral mesh?” Should a drain be used after a TEP repair? Should seromas be aspirated? Statements Level 1A Patients who receive anticoagulant are prone to afterbleed. The most frequent early complications are hematomas and seromas (8–22%). The incidence of hematomas is lower for endoscopic (4.2–13.1%) techniques than for open repair (5.6–16%). The risk of seroma formation is higher for endoscopic techniques than for open repairs. Level 1B The use of Fibrin sealant for mesh fixation during bilateral TEP leads to a significant reduction of analgesic consumption but is associated with an increased incidence of postoperative seroma. Level 3 Most seromas disappear spontaneously within 6–8 weeks. Infection after aspiration of seromas is described. Level 5 Perioperative drainage to prevent seromas is contradictory. Recommendations Grade B It is recommended that wound drains be used only when specifically indicated (large blood loss, coagulopathies). Anticoagulants should be stopped before surgery. Seromas are best not aspirated. Grade D If indicated, a closed suction drain is kept as per the assessed requirements. Incidence of seromas and hematomas are described in various studies [32, 36]. In a study, the author recommends routine use of drain, because release of carbon dioxide pressure is followed by bleeding from tiny capillaries, resulting in unpredictable amount of blood collecting in the preperitoneal space. Avoidance of postoperative hematomas is important to the achievement of a low mesh infection rate and prevention of potential mesh displacement by the collection fluid. Furthermore, drainage also ensures complete deflation and readaptation of the tissue layer . In a multi-institutional retrospective analysis, it was found that local complications, such as hematoma, seroma, and emphysema, were seen most commonly after TEP repair. Fifty-six local complications were found in 457 TEP repairs compared with a total 95 local complications in 1,514 repairs by various endoscopic techniques; the important local complications are hematoma and seroma . In a study of 400 patients who had undergone TEP repair, one patient who received anticoagulant treatment had to undergo endoscopic revision of an afterbleed . Preparation and introduction of mesh Recommendations Grade C The mesh should be taken out of its packaging just before introduction under absolutely sterile conditions. No data allow any relevant recommendations. Under absolutely sterile conditions just before introduction, the mesh is prepared to facilitate its introduction into the preperitoneal space and its placement over the myopectineal orifice. The techniques of Felix , Philip , and Chowbey et al.  are subtle variations in the preparations of the flat polypropylene mesh. Chowbey recommended cutting the mesh to a size of 15 × 13 cm, rolled superior-inferiorly for approximately two-thirds of its length and fixed with two sutures. This ensures ease of introduction and placement, following which the stitches are cut and the mesh unrolled. Golash  rolls the mesh from both the medial and lateral edges. Lal et al.  also rolls up the mesh and secures it with two Vicryl ties to introduce it into the preperitoneal space via the 10-mm telescope. Should one or two meshes be used for bilateral hernias? Statements Level 1B To treat bilateral hernias, implantation of two meshes overlapping by 1–2 cm in the midline above the pubic symphysis or one large mesh are options. Level 2B The issue stills remain unresolved as to whether two different meshes of adequate size with overlap in the midline or a single large mesh be used to treat bilateral inguinal hernias. After implantation of two meshes, the recurrences detected (direct and bilateral) suggest the presence of a weak zone in the midline despite the two meshes overlapping in the midline. Level 3 Implantation of one large mesh seems to be technically more difficult than that of two meshes. Recommendations Grade C In bilateral hernias, a sufficiently large mesh should be used or two different meshes (e.g., 15 × 13 cm on both sides). In a prospective, randomized, controlled trial of 100 patients comparing totally preperitoneal laparoscopic approach and Stoppa procedure (open), the author suggests the use of a large prosthesis rather than two small ones for bilateral hernias to minimize recurrence . Another RCT concurs due to the presence of a weak zone in the midline . A retrospective study  could not find a significant difference between the use one large or two small meshes in the totally extraperitoneal repair for bilateral inguinal hernias. Mesh placement—how much overlap? Is there any scientific basis? Are there cases for fixation? Statements Level 4/5 Mesh overlapping of less than 2–3 cm may lead to a protrusion of the mesh into the hernia opening. The larger the hernia opening the more overlapping there should be. In large direct defect, danger for protrusion of mesh into the opening is increased. Recommendations Grade C The minimum distance between the margin of the prosthesis and that of the hernial opening should be equal to the diameter of the opening in hernias of size 2 cm or larger. For smaller lesions ( 4 cm. Grade D The mesh should cover without wrinkles all the facial defects in the groin, including Hesselbach’s triangle, the indirect ring, the femoral ring, and the obturator ring. The scientific basis of mesh overlap has been explained by Hollinsky . The required mesh overlap over the hernial opening is calculated based on the distribution of adhesive force and load on the mesh. In a randomized, controlled trial, a medial overlap of mesh by some 4 cm is advised in direct unilateral hernias to prevent recurrence . How to avoid uprolling of the mesh during desufflation of pneumopreperitoneum? Statements Level 3 Uprolling of mesh is one main cause for recurrence. Insufficient preperitoneal dissection (parietalization) is the main cause for uprolling of mesh. Recommendations Grade B Extensive preperitoneal dissection is critical to prevent uprolling of mesh. Desufflation of retropneumoperitoneum should be done under vision. Grade D When fibrin sealant is used, it is applied to the Cooper’s ligament, the inferior edge, and medial corner of the mesh, which is steadied in position in graspers for a few minutes to ensure firm adhesion before desufflation. 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(2004) Randomized clinical trial of fixation vs nonfixation mesh in total extraperitoneal inguinal hernioplasty. Arch Surg 139:1376–1379. (1B) Halm JA, Heisterkamp J, Boelhouwer RU, den Hoed PT, Weidema WF (2005) Totally extraperitoneal repair for bilateral inguinal hernia. Surg Endosc 19:1373–1376. (3) Hollinsky C, Hollinsky KH (1999) Static calculations for mesh fixation by intra-abdominal pressure in laparoscopic extraperitoneal herniorrhaphy. Surg Laparosc Endosc Percutan Tech 9:106–109. (5) Scheuerlein H, Schiller A, Schneider C, Scheidbach H, Tamme C, Köckerling F (2003) Totally extraperitoneal repair of recurrent inguinal hernia. Surg Endosc 17:1072–1076. (4) Chapter 4: TEP versus TAPP: which is better for the patient? Misra Mahesh Chandra, Kumar Subodh, Bansal Virinder Kumar, Krishna Asuri Department of Surgical Disciplines, All India institute of Medical Sciences, New Delhi-29, India Comparison of the two standardized techniques of laparoscopic inguinal hernia repair (LIHR): What is better for the patient—Transabdominal Preperitoneal (TAPP) or Totally Extraperitoneal (TEP) repair? Search terms: “Inguinal hernia”; “laparoscopy”; “TAPP”; “TEP” Uncomplicated inguinal hernia Statements Level 2 A Potentially serious adverse events are rare after both TAPP and TEP. Level 3 Regarding overall complication rate, there is no obvious difference between TAPP and TEP. TAPP and TEP show a noticeable “learning curve.” TAPP has a shorter operation time in inexperienced and experienced surgeons. Level 4 TEP is more suitable for regional anesthesia. Level 5 Unsuspected hernias on the contralateral side are easier to detect with TAPP. Recommendations Grade B Both techniques are acceptable treatment options for inguinal hernia repair, but there is insufficient data to allow conclusions to be mde about relative effectiveness of TAPP compared with TEP. Grade D In selected patients having a contraindication for general anesthesia, TEP in regional anesthesia can be done. Introduction Two revolutions in the inguinal hernia surgery have occurred during the past two decades. The first was the introduction of tension-free open mesh repair (OMR) by Lichtenstein et al.  in 1989, which significantly reduced the recurrence rates. The second revolution was the application of laparoscopic surgery in the treatment of inguinal hernia during the early 1990s, which led to decrease in postoperative pain and faster recovery along with low recurrence rates . Ger et al.  reported first laparoscopic inguinal hernia repair (LIHR). Schultz et al.  were the first to report the use of prosthetic material during laparoscopic inguinal hernia repair. Discussion There is only one RCT done by Schrenk et al.  who compared TAPP and TEP inguinal hernia repairs. The authors found less early postoperative pain after TAPP (p 3–4 cm), a larger mesh may be used (12 × 17 cm). In large direct defects (>3–4 cm), a stapled fixation of the mesh to the symphysis, Cooper’s ligament and rectus muscle may be done. In large indirect defects (>4–5 cm), the overlapping of the mesh has to reach approximately 1–3 cm lateral to the spina iliaca anterior superior. In addition, fibrin fixation to the psoas muscle can be performed. In large hernia defects, a mesh with greater flexural stiffness (heavyweight) or a well-fixed lightweight mesh with adequate overlapping may be used. To reduce frequency of sero-hematomas, careful bleeding control by electrocoagulation should be done. Laparoscopic repair of the scrotal hernia is a controversial subject in laparoscopy, because it implies a large abdominal wall defect and great difficulty in dissecting the extensive hernia sac. Literature on the subject is scant. Ferzli  first described laparoscopy for scrotal hernia in 17 patients in 1996. He utilized the TEP method and had no recurrences. In 1999, Leibl addressed the subject of TAPP for the scrotal hernia. He and his colleagues analyzed the results of 191 prospectively studied TAPP repairs for scrotal hernias. They only rarely transected the sac. Operative times were slightly increased compared with normal TAPP repair. Total minor complication rate was 12% for the scrotal repair versus 5% for the normal TAPP repair, with the most common complication being seroma. Major complications were 1.6% for scrotal versus 0.6% for the normal repair. The recurrence rate was 1% . Bittner followed up this data with analysis of 440 scrotal hernias in their large, single-center series of 8,050 TAPP repairs. Overall recurrence for the series was 0.7% but 2.7% for scrotal hernias . Detailed clinical analysis and experimental studies (Hollinsky) show that the higher recurrence rate in some cases of scrotal hernias having a large defect may be due to inadequate overlapping. Other causes for recurrence in these cases may be the use of meshes with less flexural stiffness and insufficient fixation (Hollinsky) [4, 5]. Bittner’s overall morbidity was 3.2% and decreased with experience. The scrotal subgroup had a significantly increased rate of sero-hematoma (12.5%), which mandated drainage . Palanivelu also presented a small series of patients using TAPP to repair irreducible scrotal hernias with good results. TAPP for incarcerated and strangulated inguinal hernia Statements Level 3 Operation time is longer than in uncomplicated hernia. Complication rate and recurrences are similar to uncomplicated cases. Advantage of laparoscopy is that bowel viability can be observed during the whole time of procedure. Frequency of bowel resection is less compared with open hernia surgery. Level 5 Reduction of hernia content or cutting the hernia ring if necessary for reduction may be safer when overlooking both peritoneal and preperitoneal space. Recommendations Grade C TAPP may be used for the repair of incarcerated or strangulated inguinal hernias, but the technique should be reserved for surgeons with extensive experience in the TAPP technique. Grade D Compromised bowel that is encountered during TAPP repair of strangulated hernia may be resected after the completion of the TAPP repair (after allowing time for the bowel to declare its viability). The resection should be performed extracorporeally for intestine or may be performed intracorporeally for omentum or appendix. In 2001, Leibl et al.  published the results of 220 prospectively studied acutely (strangulated) and chronically incarcerated inguinal hernia repairs; 194 of these repairs were accomplished via TAPP. There was no difference in operative time comparing laparoscopic and conventional repair; however, the time of operation was significantly longer compared with elective TAPP repair. Recurrence rate for TAPP repairs of incarcerated hernias were low (0.5%) and was similar to conventional open repair of incarcerated hernias. Other complications, including bleeding, mesh infection (0.1%), organ injury, and death, were similarly low or lower. The authors noted that one advantage of the TAPP technique is that it allows assessment of the viability of the bowel. The time needed for hernia repair allows time for the congested bowel to return to normal or not. A comparison to the prelaparoscopic era shows less frequent bowel resections when performing TAPP. Resection can be performed, if needed, after repair of the hernia. Leibl’s group  has extensive experience with TAPP repair of routine hernia, and he cautions that surgeons must be comfortable with this technique in routine hernias before attempting it on a complex incarcerated hernia. Other smaller case series and case reports have shown the viability of the TAPP technique for incarcerated hernias [7–11]. The key step to the operation is the reduction of the sac and its contents. The hernia ring can be enlarged (while preventing injury to the femoral or epigastric vessels) through a ventromedial incision in the case of direct hernias and through a ventrolateral incision in the case of indirect hernias. If resection of nonviable tissue is required, it can be done intraperitoneally (for omentum or appendix) or extraperitoneally (for small bowel) after the repair has been accomplished [8, 10, 11]. TEP for incarcerated and strangulated inguinal hernia Statements Level 3 The conversion rate in the acute setting is high.Recurrence and complication rates are higher than in the nonincarcerated hernia. Level 5 A drawback to the TEP vs. TAPP approach for the strangulated inguinal hernia is that TEP does not allow inspection of the bowel without laparoscopy. Recommendations Grade C TEP may be used for repair of both incarcerated and strangulated inguinal hernias; however, the data on the subject are scant. Grade D The umbilical port can be converted from a preperitoneal port to an intraperitoneal port to assess bowel viability when it is in question. In 2004, Ferzli et al. described their experience with TEP to repair 11 acutely incarcerated inguinal hernias. Eight repairs were completed via TEP and three converted to open repairs. They describe the use of various releasing incisions to free the incarcerated sac depending on the nature of the hernia (direct, indirect, or femoral). Ferzli et al.  reported no recurrences, a single mesh infection that resolved with continuous irrigation, and a midline wound infection after bowel resection. In 2003, Tamme et al.  showed the results of a large series of TEP repairs of inguinal hernias. In this group, he includes, but does not detail, repairs performed on strangulated hernias. His overall results demonstrated low rates of recurrence and complications. Among his conclusions is that TEP is particularly advantageous for the treatment of bilateral, recurrent, and strangulated hernias versus open and TAPP repairs. He cites a reduction in postoperative neuralgia versus open repair and a reduction in bowel injury and port site hernia versus TAPP. Saggar and Sarang  retrospectively looked at 34 patients (of 286 elective TEP hernia repairs) who underwent repair of chronically incarcerated inguinal hernia using TEP. Recurrence rate was higher for incarcerated versus nonincarcerated hernias (5.8 vs. 0.35%). The recurrences in the incarcerated group (n = 2) occurred during the immediate postoperative period and 2 months postoperatively. Scrotal hematoma and cord induration also were significantly higher in the incarcerated group. He converted the umbilical port to an intraperitoneal port to inspect the bowel when its viability was in question. TAPP and TEP for incarcerated femoral hernia Statements Level 5 There are only few reports of successful treatment of incarcerated femoral hernia. Reduction of hernia contents requires incision of the lacunar ligament. Recommendations Grade D Incarcerated femoral hernia may be safely repaired via the TAPP or TEP; however, in TEP additional laparoscopy for inspection of the incarcerated hernia content is necessary. Although in some cases a plug repair was done, the general opinion is that a flat mesh having usual size should be inserted. There are currently no major reports on the use of laparoscopy for the treatment of femoral hernia although case series exist [15, 16]. Watson first reported the use of TAPP for an incarcerated femoral hernia in a 1993 case report. He used a plug and patch and resected the compromised bowel extracorporeally . Yau et al. describe a cohort of eight patients with incarcerated femoral hernias that were repaired laparoscopically by the TAPP technique. The hernia was reduced with atraumatic forceps and, if needed, the lacunar ligament was incised. After opening the preperitoneal space, a Prolene mesh was inserted into the femoral canal and the peritoneum was reapproximated over the repair. The authors opted not to lay mesh over the entire pectineal orifice in the case of an isolated femoral hernia . Rebuffat et al.  describes 7 TAPP repairs of strangulated femoral hernias in his series of 28 TAPP repairs for strangulated hernias. Comman et al.  wrote a case report of a single patient with an incarcerated femoral Littre’s (herniation of a Meckel’s diverticulum), which was treated successfully by TAPP repair. The literature on the use of TEP for incarcerated femoral hernia is even sparser than for that of TAPP. Ferzli et al.  report one case in his series of TEP for incarcerated inguinal hernias. Laparoscopic inguinal hernia repair in the setting of peritonitis and bowel necrosis Statements Level 5 A high risk for mesh infection is feared. Recommendations Grade D Laparoscopic repair of incarcerated inguinal hernia should be avoided in the setting of peritonitis and if an infected abdominal wall or intra-abdominal cavity is found on laparoscopic exploration. Laparoscopic (TAPP or TEP) repair of an incarcerated hernia should be avoided in the setting of frank peritonitis or if an infected abdominal wall is encountered in association with necrotic bowel during laparoscopic evaluation. Standard surgical principles still dictate that the risks of mesh infection and its associated complications (recurrence, draining sinus, and enterocutaneous fistula) are too great and a myofascial repair should be performed [7, 9, 12]. TAPP and TEP for recurrent inguinal hernia Recurrence of inguinal hernia is a common problem that vexes all general surgeons. Large database studies from Denmark and Sweden demonstrate that reoperation rates after first repair that range from 3.1 to 17% [20–23]. The re-recurrence rate of inguinal hernia after a repair for recurrence is even higher. Some reports state a re-recurrence rate as high as 33% . The higher re-recurrence rate of inguinal hernia after a prior recurrence results from distortion of the normal anatomy and from the replacement of the fascial strength layer with weaker scar tissue. The potential for reduction of re-recurrence after laparoscopic hernia repair stems from the use of mesh, which, as Lichtenstein demonstrated, reduces tension along the repair, thereby, reducing the rate of recurrence [25, 26]. Just as importantly, the posterior approach of the laparoscopic inguinal hernia repair not only provides the mechanical advantage of an underlay repair but also provides the technical advantage of operating through virgin tissue when performed after prior anterior repair. TAPP for recurrent inguinal hernia Statements Level IB TAPP is advantageous in terms of defining anatomy and providing improved mechanical strength. Re-recurrence rate is equal or improved when compared with open techniques. Complication rate at 1 week after surgery is less and sick leave is shorter compared with the Lichtenstein repair. Acute and chronic pain are less compared with open mesh repair. Level III Effectiveness of TAPP-repair in recurrent hernia is equal compared with TAPP repair in primary hernia. Recommendations Grade A TAPP for repair of recurrent inguinal hernia is the preferred alternative to tissue repair and to the Lichtenstein repair for recurrence after prior anterior repair. Grade B TAPP for recurrent hernia should only be performed by surgeons with extensive experience in the TAPP technique. Review of the literature from 1996 to present on the use of TAPP for repair of recurrent hernia demonstrates overall that TAPP is equal to or has a significantly better profile compared with the Lichtenstein and other open repairs in terms of re-recurrence. This is especially true for the use of TAPP after prior anterior (open) repair. These data include smaller prospective randomized trials, small and large nonrandomized prospective cohorts, and reviews of large, prospective national hernia databases. Several smaller, single-institution studies (Sandbilcher, Felix, Memon) demonstrate good re-recurrence rates for TAPP for recurrence (0.5, 0.6, and 3%, respectively). Ramshaw’s large single institution review demonstrated a 2% re-recurrence rate after TAPP for recurrence. Bittner’s re-recurrence rate (1.1%) in his large series was no different than his rate of recurrence for primary unilateral or bilateral hernia. The same was true for operation time, complication rate, and time of sick leave. Bisgaard’s large prospective study from the Danish national hernia database shows a re-recurrence rate of 1.3% for TAPP repair of recurrent inguinal hernia versus 11.3% for Lichtenstein repair of recurrent inguinal hernia. Dedemadi and Eklund demonstrated improved and equivalent re-recurrence results, respectively, for TAPP versus Lichtenstein. Furthermore, Mahon, Dedemadi, and Eklund found significantly less pain during the early postoperative period. In addition, Mahon reported significantly less chronic pain compared with open mesh repair. These and multiple other studies (most notably, Neumayer) are consistent in the finding that a significant learning curve is associated with the TAPP repair and that TAPP for recurrent hernia should only be attempted by surgeons who are very familiar with the technique [3, 20–22, 27–40]. TEP for recurrent inguinal hernia Statements Level I B TEP is advantageous in terms of defining anatomy and providing improved mechanical strength. Re-recurrence rate is equal or improved compared with open techniques. Level II C Re-operation rate is less compared with open techniques. Recommendations Grade A TEP for repair of recurrent inguinal hernia is the preferred alternative to tissue repair and to the Lichtenstein repair for recurrence after prior anterior repair. A number of studies have demonstrated that TEP repair of recurrent inguinal hernia is a viable technique that can be done with low re-recurrence and low morbidity. These studies range from case series to data prospectively collected from multicenter and large national hernia databases. They also include one prospective, randomized study with a subset analysis of laparoscopy for recurrent hernia and a prospective, controlled, nonrandomized study looking at TEP versus open repair for recurrence [31, 41]. Conversion rates to open were comparable to conversion rates of repairs for primary hernias. Re-recurrence rates after recurrent repair by TEP ranged from 0 to 20%, but most studies show a comparable or improved recurrence rate compared with the open re-repair [42, 43]. Ramshaw’s large single institution study had a re-recurrence rate of 0.3% after TEP . The study by Bay-Nielson et al.  showed a reoperation of 1.3% after TEP for recurrence versus 3.2 and 6.7% respectively for the Lichtenstein and muscle repair for recurrence. These results were later reconfirmed when his group looked at all laparoscopy for recurrence . One drawback to the technique, as Ferzli and Sayad point out, is that sutures or scarring from the prior repair may result in inadvertent pneumoperitoneum. This results in a technical obstacle to repair, but the challenge can be overcome with experience . Again, most authors emphasize the importance of the steep learning curve with this technique and caution that only surgeons who are well trained in the TEP technique utilize it for recurrent hernia [20, 21, 29, 34, 36, 40–54]. Pain score and return to regular activity after TAPP and TEP for recurrent inguinal hernia Statements Level IB Compared with open repair, TAPP and TEP have a better profile in terms of level of pain and return to regular activity. Incidence of wound and mesh infection is lower compared with open hernia surgery. Level IV Effectiveness of TAPP versus TEP is similar. Recommendations Grade A Both techniques TAPP and TEP are recommended after an anterior approach, providing the surgeon is sufficiently experienced in the specific procedure. The long skin incision and myofascial dissection of an open inguinal hernia repair create significant postoperative pain, resulting in prolonged recuperation and in delayed return to normal activity and return to work. TAPP has been directly compared in a number of retrospective and small, randomized, prospective studies to open repair for recurrent hernia and has been shown to be associated with significantly decreased postoperative pain and earlier return to work and activity. The incidence of wound and mesh infections also has been demonstrated to be lower [27–31, 44, 55–58]. TAPP and TEP seem to be similarly effective, although there is a scarcity of data comparing both techniques directly . TAPP inguinal hernia repair after failed TAPP/TEP Statements Level III Re-TAPP is possible. Operation time is longer and morbidity higher compared with repair of primary hernia, but time of sick leave and re-recurrence rate are similar. There is a steep learning curve. Level IV/V TAPP is superior to TEP. Recommendations Grade C TAPP repair of recurrent inguinal hernia after prior TAPP or TEP may be performed; however, it should only be attempted by experts in TAPP inguinal hernia repair. According to EHS Guidelines, it is generally agreed that an anterior approach seems to be the best choice after failed posterior repair. Yet, a number of studies have looked at TAPP repair for recurrence after TAPP as the primary repair modality (TAPP after TAPP). Most show excellent results. Bisgaard’s review from the Danish hernia registry is the exception. The recurrence rate of 7.1% for TAPP vs. 2.7% for Lichtenstein repair may stem from the fact that this is a national study and includes all comers (expert and novice laparoscopic surgeons alike). Bisgaard’s  review highlights the need for a high level of experience and comfort in the basic TAPP technique before attempting its use for TAPP after TAPP. Indeed, the largest series of TAPP after TAPP, Bittner (n = 135), demonstrates a significant learning curve, but with a low overall re-recurrence rate of 0.74% [20, 31, 59–61]. TAPP and TEP repair in patient after previous transabdominal radical prostatectomy Statements Level 3 TAPP and TEP are possible treatment options. Operation time is longer and morbidity higher compared with repair of primary hernia, but time of sick leave and re-recurrence rate are similar. There is a steep learning curve. In TEP, there is a significant conversion rate to TAPP. Level 5 TAPP seems to be easier to perform. Recommendations Grade D TAPP or TEP repair may be performed, but it should only be attempted by experts in TAPP or TEP inguinal hernia repair. It is generally accepted that an anterior approach seems to be the best choice after previous preperitoneal surgery. Only two studies report the results of TAPP (Wauschkuhn et al. ) and TEP (Dulucq et al. ) in hernia patients after previous transabdominal radical prostatectomy. During a 1-year period, Dulucq operated on a total of 10 patients after prostatectomy with TEP. Operation time was longer than in uncomplicated repairs and two patients were converted to TAPP, but overall complication rate and outcome were similar. Wauschkuhn et al. report approximately 264 patients who underwent surgery during a 10-year period. They found a longer operation time and a higher morbidity (5.7 vs. 2.8), but time of slick leave and recurrence rates were similar. Analysis of subgroups with respect to the time period during which they were operated on showed a steep learning curve [62, 63]. Pitfalls of TAPP and TEP repair for recurrent inguinal hernia Statements Level 4 The presence of two or more meshes in the inguinal region does not seem to enhance the frequency of chronic pain. Removal of a previously implanted preperitoneal mesh may increase the risk for lesion of urinary bladder, bleeding complications, and substantial defects of the peritoneum. Recommendations Grade D Old mesh from prior preperitoneal hernia repair should be left in place. The re-repair should be defect-adapted. When an old plug is encountered that does not allow placement of a flat mesh, the protruding part of the plug may be best cut away with the use of electrocautery. The presence of old mesh in the prior hernia repair presents a technical challenge for TAPP or TEP repairs of recurrence. The mesh from a prior Lichtenstein repair should not affect the field of a posterior approach. However, the mesh plug technique poses a unique problem for laparoscopic repair of recurrence. The old plug creates an obstacle to placing the mesh and replacing the peritoneum over the mesh. Removal of the plug is not simple and cannot be easily accomplished with endo-shears. We find that electrocautery more effectively cuts the protruding aspect of the plug, thus allowing posterior mesh placement and replacement and repair of the peritoneum. The best approach to a mesh placed from prior laparoscopic repairs may be to leave it in place and avoid risk of injury to the iliac vein or to the bladder. The new mesh can be laid on top of the old to correct any technical failure of a slipped or misplaced prior mesh. TAPP and TEP repair and the occult synchronous hernias. Statements Level 4 TAPP and TEP repair of inguinal hernia allow easy identification of the occult ipsilateral femoral or obturator hernia. TEP allows easy identification of concomitant contralateral direct hernias. TAPP allows easy identification of concomitant contralateral direct and indirect hernias. The laparoscopic approach obliterates these associated occult synchronous or potential hernias utilizing a single repair without any particular modification to the technique. Recommendations Grade B In inguinal hernia repair for diagnosis of occult ipsilateral hernia defects, a careful dissection of the whole pelvic floor should be done. One problem associated with the repair of the recurrent inguinal hernia repair is the missed synchronous hernia . Felix et al.  found an occult femoral hernia incidence of 9% in his 1996 series of laparoscopic repair of recurrent inguinal hernia. Mikkelsen et al. found the risk of femoral hernia to be 15 times higher after inguinal hernia repair than in the general population, and Chan believes prior inguinal hernia repair may precipitate femoral hernia [65, 66]. He found that 50.9% of his series of 225 femoral hernia repairs had concurrent inguinal hernia and 18.2% had prior groin hernia repair. Laparoscopic inguinal hernia repair provides the benefit of a panoramic view of the all the potential hernia spaces: direct and indirect, femoral, and obturator hernias. TAPP and TEP therefore address the missed femoral and concomitant ipsilateral hernias. Furthermore, TAPP enables rapid evaluation of contralateral hernias (see Chap. 2, Kukleta). The laparoscopic approach obliterates these associated occult synchronous or potential hernias utilizing a single repair without any particular modification to the technique. 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(1a) Bringman S, Ramel S, Heikkinen TJ, Englund T, Westman B, Anderberg B (2003) Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: a prospective randomized controlled trial. Ann Surg 237:142–147. (1b) Kuhry E, van Veen RN, Langeveld HR, Steyerberg EW, Jeekel J, Bonjer HJ (2007) Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review. Surg Endosc 21:161–166. (1a) Bittner R, Schwarz J (2007) How to treat recurrent inguinal hernia—TAPP. In: Schumpelick V, Fitzgibbons JR (eds) Recurrent hernia. Prevention and treatment. Heidelberg, Springer, pp 297–301. (4) Knook MT et al. (1999) Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy. 13:1145–1147. (4) Leibl B et al. (2000) Recurrence after endoscopic transperitoneal hernia repair (TAPP): causes, reparative techniques, and results of the reoperation. J Am Coll Surg 190:651–655. (4) Wauschkuhn CA, Schwarz J, Bittner R (2009) Laparoscopic transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: is it safe? Results of prospectively collected date of more than 200 cases. Surg Endosc 23:973–977. (4) Dulucq JL, Wintringer P, Mahajna A (2006) Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or lower abdominal surgery: is it safe?A prospective study. Surg Endosc 20: 473–476. (4) Crawford DL, et al. (1998) Laparoscopy identifies unexpected groin hernias. Am Surg 64:976–978. (4) Mikkelsen T et al. (2002) Risk of femoral hernia after inguinal herniorrhaphy. Br J Surg 89:486–488. (2c) Chan G, Chan CK (2008) Long-term results of a prospective study of 225 femoral hernia repairs: Indications for tissue and mesh repair. J Am Coll Surg 207:360–367. (4) Chapter 6: Mesh size and recurrence: what is the optimal size? Thue Bisgaard, Jacob Rosenberg Copenhagen, Denmark Search terms: “mesh size”; “recurrence”; “inguinal hernia” Does the use of a larger mesh prevent recurrence after laparoscopic inguinal hernia repair? Statements Level 2A A small mesh may be a risk factor for recurrence after laparoscopic inguinal hernia repair. Level 5 Insufficient dissection of the preperitoneal space makes it difficult to place a large mesh properly and avoid folds and wrinkles. Fixation does not compensate for inadequate mesh size. Recommendations Grade A A mesh size of at least 10 × 15 cm is recommended. Grade D Use a bigger mesh (i.e., 12 × 17 cm or greater) for large hernias (direct >3–4 cm, indirect >4–5 cm). A systematic literature search was performed in PubMed covering the period from 1966 to January 2009. Papers in English, German, and French were reviewed. Only human studies were included. The following search terms were used: mesh size, recurrence, inguinal hernia. Mesh size may have a greater impact on recurrence than surgical technique [1, 2]. A small mesh has been shown to be an independent risk factor for recurrence compared with a large one, irrespective of the type of mesh, i.e., light or heavyweight . We found no randomized trials that specifically compared mesh sizes, but several studies on surgical techniques used different sizes of mesh. Data extracted from a recent meta-analysis of open versus laparoscopic hernia repairs provide some information about this issue . A significant trend toward reduced recurrence rates with increasing mesh size was noted (a “large” mesh was most often 10 × 15 cm2 size). Indeed, use of a small mesh almost doubled the risk for recurrence . A large, retrospective series that included 3,017 patients who underwent TAPP inguinal herniorrhaphies showed a 5% recurrence rate using an 11 × 6 cm2 mesh in 325 repairs and a 0.16% recurrence rate using a 15 × 10 cm2 mesh in 3,205 repairs . There are two large randomized studies from Sweden; one compared TAPP with Shouldice with a 5-year follow-up of 920 patients and showed a recurrence rate of 6.6% when using a mesh size of 7 × 12 cm2 , and the other compared TEP with Lichtenstein with 5-year clinical examination of 1,370 patients when using a mesh size of 12 × 15 cm2 and showed a recurrence rate of 3–5% . Animal data have suggested that a minimum of 3-cm mesh overlap is essential to prevent mesh protrusion through the hernia defect resulting in recurrence . To summarize, the use of a large mesh for laparoscopic inguinal hernia repair is supported by the literature, albeit with a low level of evidence, which makes it impossible to recommend an optimal size. However, it seems reasonable to suggest that the mesh should overlap the hernia defect by at least 3 cm in all directions. It should be emphasized that dissection of the preperitoneal space has to be adequate for the size of mesh to ensure that the mesh lies flat against the abdominal wall [9–11]. Comprehensive comments As recurrence factor, mesh size is much more important than the prosthetic material used. In daily clinical practice, we use a mesh of 10 × 15 cm2 size, even in “small” patients. If the patient is big or has a large hernia defect, it is advisable to use a larger mesh. However, for logistic reasons, we have decided to use only 10 × 15 cm2 meshes in our departments, and if we encounter a patient who requires a larger mesh, we simply implant two meshes instead of one with sufficient overlap. Some surgeons routinely cut the mesh making it curved, i.e., rounding the edges. This is not necessary. Instead, the dissection should be thorough with a complete parietalization and a wide exposure of the entire preperitoneal space to ensure a flat positioning of the mesh. References (in parentheses graduation of evidence) Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, Henderson W; Veterans Affairs Cooperative Studies Program 456 Investigators (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350:1819–1827. (1B) Neumayer L, Giobbi-Hurder A, Jonasson O (2004) Open mesh versus laparoscopic mesh hernia repair (authors reply). N Engl J Med 351:1463–1465. (4) Lowham AS, Filipi CJ, Fitzgibbons RJ Jr, Stoppa R, Wantz GE, Felix EL, Crafton WB (1997) Mechanisms of hernia recurrence after preperitoneal mesh repair. Ann Surg 225:422–431. (2B) Stengel D, Bauwens K, Ekkernkamp A (2004) Recurrence risks in randomized trials of laparoscopic versus open inguinal hernia repair: to pool or not to pool (this is not the question). Langenbecks Arch Surg 389:492–498. (2A) Kapiris SA, Brough WA, Royston CM, O’Boyle C, Sedman PC (2001) Laparoscopic transabdominal preperitoneal (TAPP) hernia repair. A 7-year two-center experience in 3,017 patients. Surg Endosc 15:972–975. (2C) Arvidsson D, Berndsen FH, Larsson LG, Leijonmarck C-E, Rimbäck G, Rudberg C, Smedberg S, Spangen L, Montgomery A (2005) Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia. Br J Surg 92:1085–1091. (IB) Eklund AS, Montgomery A, Rasmussen C, Sandbue RP, Bergkvist LA, Rudberg CR (2009) Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair. A randomized, multicenter trial with 5-year follow-up. Ann Surg 249:33–38. (IB) Knook MT, van Rosmalen AC, Yoder BE, Kleinrensink GJ, Snijders CJ, Looman CW, van Steensel CJ (2001) Optimal mesh size for endoscopic inguinal hernia repair, a study in a porcine model. Surg Endosc 15:1471–1477. (5) Totte E, Van Hee R, Kox E, Hendrickx L, Van Zwieten KJ (2005) Surgical anatomy of the inguinal region: implications during inguinal laparoscopic herniorrhaphy. Eur Surg Res 37:185–190. (5) Lowham AS, Filipi CJ, Fitzgibbons RJ Jr, Stoppa R, Wantz GE, Felix EL, Crafton WB (1997) Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic. Ann Surg. 225:422–431 (4, videotapes from 13 recurrence operations analysed by experts). (4) Phillips EH, Rosenthal R, Fallas M, Carroll B, Arregui M, Corbitt J, Fitzgibbons R, Seid A, Schultz L, Toy F et al. (1995) Reasons for early recurrence following laparoscopic hernioplasty. Surg Endosc 9:140–144. (2C) Chapter 7: Selection of mesh material D. Weyhe, C. Schug-Pass, U. Klinge Search terms: “TAPP” AND “mesh”; TEP AND “mesh”; “Biocompatibility” AND “mesh”; “groin pain” AND “mesh”; “inguinal hernia” AND “mesh”; “Quality of life” AND “mesh” Does functional outcome and quality of life improve with the use of light meshes in TAPP and TEP? Statements Level 1A In the long-term comparison, lighter meshes with larger pores do not lead to improvements of the quality of life or a reduction of discomfort that are of statistical significance. They offer advantages in terms of convalescence during the first few postoperative weeks. Recommendations Grade B The hernia repair in the TAPP/TEP technique with a so-called material-reduced mesh (less amount of material, bigger pores, some elasticity) decreases the rate of mesh-related complaints, at least within the first 3 months. Grade D A monofilament implant with a pore size of at least 1.0–1.5 mm (usually meaning low-weight) consisting of a minimum tensile strength in all directions (including subsequent tearing force) of >16 N/cm appeared to be most advantageous; however, this assumption mainly summarizes personal and published clinical and experimental experiences. Introduction The common approach in hernia surgery is the tension-free technique with alloplastic materials to strengthen the connective tissue or partial connective tissue replacement in large fascia defects. Modern implants have to fulfill increasingly stringent requirements concerning their mechanical and biological qualities. A large number of investigations deal with the improvement of the biocompatibility of implants. In this respect, the definition of biocompatibility moves away from the concept of a biochemical inert material to an application-oriented definition. In the past, a variety of experimental studies were performed to improve the implants to prevent undesirable effects, such as chronic groin pain or movement-dependent discomfort, and allow quicker return to work and daily activities. Against this background, the light mesh concept has established itself over the years. An analysis of prospective, randomized, double blind studies that compared the theoretical effect of weight reduction to clinical outcome should result in a recommendation of the choice of mesh in TAPP and TEP technique based on the strength of the evidence. Materials and methods The clinical studies analyzed were conducted between January 2000 and February 2009, because no comparable studies are available before this period. We conducted a search of Pubmed, Medline, and Cochrane Library using the terms: TAPP/TEP and mesh, biocompatibility and mesh, groin and mesh. We analyzed each article. The classification in degrees of evidence followed the Oxford hierarchy of evidence starting from Level 1A (systematic review of RCTs with consistent results from individual studies) up to level 5 (expert opinion, animal, or lab experiments). Results TAPP In total, 374 hits were found from January 2000 to February 2009. Excluding 48 review articles, 326 publications were classified according to the evidence criteria. The result was three articles [1–3; Study design Figs. 1–3] (0.92%) based on a prospective study design, of which only two [2, 3] performed randomization (0.6%). Early results (3 months) are described in one article , medium-term results (12-month follow-up) likewise in one article , and 5-year long-term results in one study . TEP The TEP search resulted in 359 articles. Excluding 42 review articles, 317 articles were (peer) reviewed. Three of 317 (0.94%) publications were prospective, controlled, randomized studies [4–6; Study design Fig. 4–6]. Two articles [4, 5] described early results (2 months) and one  medium-term results. Long-term results were not available. Apart from the article by Horstmann et al., only five articles seem to be comparable (Table 1) [2–6]. This prospective, longitudinal study  continues to be taken into consideration despite the insufficiently standardized methodology; however, it is critically discussed in the overall analysis and separately assessed (Level 2B). The five analysed RCT studies (Level 1B) agree that postsurgical advantages last for up to 3 months. These advantages are partly very subtle and not always corroborated by the VAS and SF score (Tables 1, 2). Only one study (TAPP) has a survey of 5 years and could not detect any difference of statistical significance. Noteworthy, this long-term study reported on 5% of patients complaining about discomfort, similarly for three different mesh materials tested (smooth heavyweight, rigid ultra heavyweight, lightweight). There was no significant difference in the hernia recurrence rate in the long-term comparison between HM and LM. Table 1 Overview of the study methods and assessment of the level of evidence Randomized d- blind VAS SF-36 Multicenter Level TAPP  No No No No No 2b TAPP  Yes Yes Yes Yes No 1b TAPP  Yes Yes Yes Yes No 1b TEP  Yes Single Yes Yes Yes 1b TEP  Yes Single Yes Yes Yes 1b TEP  Yes Yes Yes No No 1b Accordance 5 3 5 4 2 – Study  is not comparable to the other Table 2 Overview of the significant advantages of LM in the early, medium-, and long-term results No. patients Follow-up (%) 60 g/m2), whereas those with large pores are “low” weight. However, there are no precisely defined limits, there are some meshes with low weight but small pores (e.g., Mersilene), and some heavyweight polymers despite large pores (e.g., made of PVDF). Because porosity is more difficult to measure than weight, the term most often used by manufacturers is “weight,” and therefore, this is used in this text too. Table 3 Textile requirements to synthetic meshes for TAPP/TEP technique Min. standard keyword 1. Monofile structure–infection 2. Pore size 1–1.5-mm collagen (large pores usually are related with low weight) 3. Tensile strength >16 N/cm stability The hernia repair in the TAPP/TEP technique using a monofilament implant with a pore size of at least 1.0–1.5 mm (usually meaning low weight) consisting of a minimum tensile strength in all directions (including subsequent tearing force) >16 N/cm appears to be most advantageous, summarizing personal and published clinical and experimental experiences (Figs. 1, 2, 3, 4, 5). Fig. 1 Study design of the prospective comparison of the postoperative quality of life after light mesh, extra light mesh, and heavy mesh implants with TAPP  Fig. 2 Prospective, double blind study to compare the quality of life concerning heavy mesh, extra heavy mesh, and light mesh implants in TAPP  Fig. 3 Long-term study with a 5-year follow-up to compare the quality of life and recurrence rate for smooth heavy mesh (HM), rigid ultra heavy mesh (UHM), and light mesh implants (LM) bei TAPP  Fig. 4 Design of the 2-arm studies to compare the early results 8 weeks postoperatively for heavy versus light mesh implants in TEP technique at bilateral hernia repair  and at unilateral recurrent hernias  Fig. 5 Study design of the Agarwal study with 12 months of follow-up  References (in parentheses graduation of evidence) Horstmann R, Hellwig M, Classen C, Röttgermann S, Palmes D (2006) Impact of polypropylene amount on functional outcome and quality of life after inguinal hernia repair by the TAPP procedure using pure, mixed and titanium coated meshes. World J Surg 30:1742–1749. [2B] Langenbach MR, Schmidt J, Zirngibl H (2006) Comparison of biomaterials:three meshes and TAPP for inguinal hernia. Surg Endosc 20:1511–1117. [1B] Langenbach MR, Schmidt J, Ubrig B, Zirngibl H (2008) Sixty-month follow- up after endoscopic inguinal hernia repair with three types of mesh: a prospective randomized trial. Surg Endosc 22:1790–1797. [1B] Bringmann S, Wollert S, Osterberg J, Heikkinen T (2005) Early results of a randomized multicenter trial comparing Prolene and Vypro II mesh in bilateral endoscopic extraperitoneal hernioplast (TEP). Surg Endosc 19:536–540. [1B] Heikkinen T, Wollert S,.Österberg J, Smedberg S (2006) Early results of a randomized trial comparing Prolene and Vypro II mesh in endoscopic extraperitoneal inguinal hernia repair (TEP) of recurrent unilateral hernias. Hernia 10:34–40. [1B] Agarwal BB, Agarwal KA, Mahajan KC (2009) Prospective double- blind randomized controlled study comparing heavy- and lightweight polypropylene mesh in totally extraperitoneal repair of inguinal hernia: early results. Surg Endosc 23:242–247. [1B] Chapter 8: Cutting or not cutting of mesh: does it influence the recurrence rate? Thue Bisgaard, Jacob Rosenberg Copenhagen, Denmark Search terms: “mesh”; “inguinal hernia”; “cutting”; “slit” Should the mesh have a slit or not to surround the spermatic cord? Statements Level 3 Cutting a slit in the mesh to allow the structures of the funicle to pass through the mesh may be a risk factor for recurrence after laparoscopic inguinal hernia repair. Level 1B An intact mesh does not produce more postoperative complications or higher risk of recurrences compared with a cut mesh. Recommendations Grade B We recommend not to cut a slit in the mesh. A systematic literature search was performed in PubMed covering the period 1966 to January 2009. Papers in English, German, and French were accepted. Only human studies were included. We identified one randomized trial . In this three-armed study, including 360 patients, a TAPP procedure was performed. In group A, the mesh was implanted through a central incision, creating a deep inguinal ring by overlapping the two incised sides. In groups B and C, a non-incised mesh was used, which was fixed with staples in group B and with nonresorbable sutures in group C. The authors reported no significant differences between the groups regarding operation times, postoperative complaints, and need for pain killers. Furthermore, they found only one recurrence in group C (no recurrences in groups A and B). Moreover, we found one comparative study with historical controls , including 2,700 TAPP procedures from a single institution. After a median follow-up time of 26 months, there were 28 recurrences, 9 (0.3%) of which were due to insufficient closure of the mesh slit. From the same institution, a later prospective study involving 8,050 procedures without slit in the mesh reported an overall recurrence rate of 0.4% . Thus, there is no evidence to support use of a slit in the mesh for laparoscopic inguinal hernia repair. One study found some of the recurrences to be associated with insufficient closure of the mesh slit. This could argue against slitting the mesh at all. Comprehensive comments Routinely, we do not cut a slit in the mesh, because it does not bring any technical advantage for the surgeon or better clinical results for the patient. References (in parentheses graduation of evidence) Leibl BJ, Kraft B, Redecke JD, Schmedt CG, Ulrich M, Kraft K, Bittner R (2002) Are postoperative complaints and complications influenced by different techniques in fashioning and fixing the mesh in transperitoneal laparoscopic hernioplasty? Results of a prospective randomized trial. World J Surg 26:1481–1484. (2B) Leibl BJ, Schmedt C-G, Schwarz J et al. (1998) A single institution’s experience with transperitoneal laparoscopic hernia repair. Am J Surg 175:446–452. (2C) Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ (2002) Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg 89:1062–1066. (2B) Chapter 9: Mesh fixation modalities: is there an association with acute or chronic pain? Esther Kuhry, Agneta Montgomery, Wolfgang Reinpold, Rene Fortelny Is it necessary to fixate the mesh in endoscopic inguinal hernia repair? What kind of fixation is to be preferred? Is type of fixation associated with acute and chronic pain? Search terms: “Surgical Mesh (MeSH)” AND “Surgical fixation device” (MeSH) AND “Inguinal Hernia” (MeSH); “fixation AND mesh AND TEP”; “fixation AND mesh AND TAPP”; “TAPP AND pain”; “TEP AND pain”; “groin hernia AND pain”; “inguinal hernia AND pain” Statements Level 1B Fixation and nonfixation of the mesh are associated with equally low recurrence rates in both TAPP and TEP; however, in most studies the hernia opening was small ( 1 mm) monofilament meshes should be considered (see Chapter “Mesh”). Regarding frequency of chronic pain, the use of light and heavyweight meshes can be considered (see Chapter “Mesh”). To reduce the risk of acute and chronic pain and discomfort, nonfixation of the mesh or fibrin glue fixation should be preferred to staples fixation (see Chapter “Fixation”). Endoscopic groin hernia repair should be considered in patients with risk factors for acute and chronic pain if expertise is present. Bilateral TAPP and TEP repair can be recommended without a higher risk of acute and chronic pain. Grade D Every endoscopic groin hernia surgeon has to be familiar with the anatomy of the inguinal nerves. The use of penetrating fixation devices in the “trapezoid of pain” and “triangle of doom” is prohibited. The nerves should not be exposed, leaving the protecting nerve fascia intact. Electrocautery has to be used with care. Pain and sensory disturbances after endoscopic and open groin hernia repair According to Aasvang et al. , the overall incidence of chronic pain after open groin hernia repair is 18% (range, 0–75.5%) and 6% after endoscopic repair (range, 1–16%; p 500 cc have been found to be predictive . Type of procedure (TEP vs. TAPP), surgical time, anesthesia time, intraoperative fluid restriction, or the development of other complications do not appear to be significant risk factors. Intermittent catheterization or temporary placement of an indwelling urinary catheter is usually adequate therapy. Urinary infection Statements Level 2B Incidence is highest in patients older than aged 74 years or who have a urinary catheter placed. Recommendations Grade B Antibiotic prophylaxis should be considered in patients at risk for infection .Urinary catheterization should be avoided if at all possible. Miscellaneous cord and testicular problems Statements Level 1a Testicular complications occur after both open and endoscopic hernia surgery. No significant difference in incidence between open and laparoscopic techniques was found in a large comparative trial and a Cochrane analysis did not show any difference between TEP and TAPP [20–22]. Scrotal hematomas can be prevented after LIH if complete hemostasis is assured before completing the procedure. Conservative treatment (ice, scrotal support, pain management, and observation) is sufficient for most, but large hematomas may require surgical drainage. Patients with bleeding disorders are especially prone to this complication . Hydroceles can develop but the cause is not known. Whereas urological literature suggests that this is due to the practice of leaving the distal sac in situ, most experienced hernia surgeons do not accept this theory. The treatment is the same as for any other hydrocele. It is important to differentiate a hydrocele from a seroma because the later is almost always self-limiting and will resolve without treatment . Ischemic orchitis/testicular atrophy Statements Level IA Unequivocal evidence that LIH will decrease the incidence of orchitis/testicular atrophy is not available. Level III In most cases, complete dissection and reduction of the hernia sac is possible without serious risk of orchitis or testicular atrophy. Recommendations Grade B In herniorrhaphies where there is a question that damage to the cord structures could occur with complete excision (e.g., large inguinal-scrotal hernias, sacs extending all the way to the testicle, densely adherent sacs), the surgeon should consider dividing the sac at a convenient point distal to the internal inguinal ring, leaving the distal sac in situ. The proximal sac should then be ligated. Orchitis is defined as postoperative inflammation of the testicle occurring within 1–5 days after surgery. It is felt to be due to acute thrombosis of the delicate venous pampiniform plexus rather than an arterial injury [25, 26]. It is most common after an inguinal scrotal herniorrhaphy when extensive dissection of the spermatic cord has been performed. The presenting symptoms are a low-grade fever with a painful, enlarged, firm testicle. The differential diagnosis includes scrotal hematoma and testicular torsion. Management is supportive with scrotal support and anti-inflammatory agents. Duplex ultrasound scanning is useful when infarction is suspected. Ischemic orchitis may result in testicular necrosis within days or have a slower course resulting in testicular atrophy during a period of several months. Fortunately most patients recover from ischemic orchitis uneventfully without testicular atrophy. Interestingly, most patients who develop testicular atrophy do not give a history of orchitis. It is not yet known whether laparoscopy will have an advantage over conventional surgery because of the more proximal dissection in the preperitoneal space. However, in one large analysis of a prospectively maintained database containing of 8,050 TAPP laparoscopic hernia repairs, orchitis and testicular atrophy was reported to be extremely low at 0.1 and 0.05% respectively. Interestingly, this group removes all indirect sacs despite the size except in rare circumstances of excessive inflammation . Nevertheless, based primarily of the extensive writings of the late George Wantz, undue dissection of the cord and testicle to remove an indirect inguinal hernia sac completely is not recommended [25, 27–30]. The hernia sac can be divided at a convenient point in the inguinal canal with the distal aspect left open. The proximal sac is then dissected from the cord structures and ligated. Sexual dysfunction Postherniorrhaphy impairment of sexual activity to a moderate or severe degree occurs in a small percentage of men after groin hernia repair, primarily inguinal scrotal or ejaculatory pain. In a Danish study, the incidence of substantial pain during sexual activity was higher with laparoscopic inguinal hernia repair compared with a Lichtenstein TFR (12.7 vs. 6.5%), but this may have been related to the greater use of LIH for recurrent hernias . The cause is not completely understood. There is no consistently effective therapy, but alpha receptor blockers to decrease contractility of the Vas and neurolytic agents, such as Pregabalin, have been tried . Recommendations Grade C Caution when dissecting the cord structures must be exercised to avoid the possibility of injury to the vas deferens or blood supply of the testicle. Infertility Injury to the vas deferens can occur during LIH, and if bilateral will lead to certain infertility. The vas deferens may be injured during dissection and mobilization or during fixation of the mesh. Unilateral injury to the vas can lead to the exposure of spermatozoa to the immune system and the formation of antisperm antibodies, causing secondary infertility . Bilateral testicular atrophy (discussed earlier) is another cause. A recent study that detailed 14 patients whose infertility was apparently the result of damage to the spermatic cord caused by the normal fibroplastic response to polypropylene mesh resulting in obstruction of the of the vas deferens included 10 open procedures, 2 laparoscopic, and 2 where laparoscopy was used on one side and open on the other . However, the explanation for their findings might be a more traditional injury mechanism at the time of surgery, such as ligation, division, or cauterization followed by scarring to the moist convenient adjacent structure, which in this case would be the mesh . References (in parentheses graduation of evidence) Ramchandani P, Buckler PM (2009) Imaging of genitourinary trauma. AJR Am J Roentgenol 192:1514–1523. (2C) Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R (2000) Recurrence after endoscopic transperitoneal hernia repair (TAPP): causes, reparative techniques, and results of the reoperation. J Am Coll Surg 190:651–655. (4) Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ (2002) Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg 89:1062–1066. (2A) Kapiris SA, Brough WA, Royston CM, O’Boyle C, Sedman PC (2001) Laparoscopic transabdominal preperitoneal (TAPP) hernia repair. A 7-year two-center experience in 3017 patients. Surg Endosc 15:972–975. (4) Hamouda A, Kennedy J, Grant N, Nigam A, Karanjia N (2009) Mesh erosion into the urinary bladder following laparoscopic inguinal hernia repair; is this the tip of the iceberg? Hernia 14:314–349. (4) Baldassarre E, Valenti G, Porta IP, Vigano M (2006) Re: Mesh migration into the bladder after TEP repair: a rare case report. Surg Laparosc Endosc Percutan Tech 16:52-53. Surg Laparosc Endosc Percutan Tech 16:377–378. (4) Kurukahvecioglu O, Ege B, Yazicioglu O, Tezel E, Ersoy E (2007) Polytetrafluoroethylene prosthesis migration into the bladder after laparoscopic hernia repair: a case report. Surg Laparosc Endosc Percutan Tech 17:474–476. (4) Agrawal A, Avill R (2006) Mesh migration following repair of inguinal hernia: a case report and review of literature. Hernia 10:79–82. (4) Jensen P, Mikkelsen T, Kehlet H (2002) Postherniorrhaphy urinary retention–effect of local, regional, and general anesthesia: a review. Reg Anesth Pain Med 27:612–617. (2A) Finley RK Jr, Miller SF, Jones LM (1991) Elimination of urinary retention following inguinal herniorrhaphy. Am Surg 57:486–488; discussion 488–489. (3) Winslow ER, Quasebarth M, Brunt LM (2004) Perioperative outcomes and complications of open vs laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice. Surg Endosc 18:221–227. (3) van Veen RN, Mahabier C, Dawson I, Hop WC, Kok NF, Lange JF, Jeekel J (2008) Spinal or local anesthesia in Lichtenstein hernia repair: A randomized controlled trial. Ann Surg 247(3):428–433. (1B) Dulucq JL, Wintringer P, Mahajna A (2009) Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years. Surg Endosc 23:482-486. (4) Koch CA, Grinberg GG, Farley DR (2006) Incidence and risk factors for urinary retention after endoscopic hernia repair. Am J Surg 191(3):381–385. (3) Vidovic D, Kirac I, Glavan E, Filipovic-Cugura J, Ledinsky M, Bekavac-Beslin M (2007) Laparoscopic totally extraperitoneal hernia repair versus open Lichtenstein hernia repair: Results and complications. J Laparoendosc Adv Surg Tech A 17:585–590. (3) Mazeh H, Beglaibter N, Grinbaum R, Samet Y, Badriyyah M, Zamir O, Freund HR (2008) Laparoscopic inguinal hernia repair on a general surgery ward: 5 years’ experience. J Laparoendosc Adv Surg Tech A 18:373–376. (4) Aeberhard P, Klaiber C, Meyenberg A, Osterwalder A, Tschudi J (1999) Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the swiss association for laparoscopic and thoracoscopic surgery (SALTC). Surg Endosc 13:1115–1120. (2C) Lau H, Patil NG, Yuen WK, Lee F (2002) Urinary retention following endoscopic totally extraperitoneal inguinal hernioplasty. Surg Endosc 16:1547–1550. (3) Schmedt CG, Sauerland S, Bittner R (2005) Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc 19:188–199. (1A) Pessaux P, Lermite E, Blezel E, Msika S, Hay JM, Flamant Y, Deepak V, Arnaud JP (2006) Predictive risk score for infection after inguinal hernia repair. Am J Surg 192(2):165–171. (3) Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant AM (2005) Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database Syst Rev (1):CD004703. (2A) Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, Henderson W (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350:1819–1827. (1B) Shah DK, Sagar J (2008) Massive penoscrotal haematoma following inguinal hernia repair: a case report. J Med Case Reports 2:357. (4) Lau H, Lee F (2003) Seroma following endoscopic extraperitoneal inguinal hernioplasty. Surg Endosc 17:1773–1777. (4) Wantz GE (1993) Testicular atrophy and chronic residual neuralgia as risks of inguinal hernioplasty. Surg Clin North Am 73:571–581. (4) Moore JB, Hasenboehler EA (2007) Orchiectomy as a result of ischemic orchitis after laparoscopic inguinal hernia repair: case report of a rare complication. Patient Saf Surg 1:3. (5) Wantz GE (1991) Testicular atrophy. A risk of inguinal hernioplasty. Chirurgie 117:645–651; discussion 651–652. (4) Wantz GE (1986) Testicular atrophy as a sequela of inguinal hernioplasty. Int Surg 71:159–163. (4) Wantz GE (1982) Testicular atrophy as a risk inguinal hernioplasty. Surg Gynecol Obstet 154:570–571. (4) Wantz GE (1984) Complications of inguinal hernial repair. Surg Clin North Am 64:287–298. (4) Aasvang EK, Mohl B, Bay-Nielsen M, Kehlet H (2006) Pain-related sexual dysfunction after inguinal herniorrhaphy. Pain 122:258–263. (4) Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH (2005) Algorithm for neuropathic pain treatment: an evidence-based proposal. Pain 118:289–305. (1A) Chehval MJ, Doshi R, Kidd CF, Winkelmann T, Chehval V (2002) Antisperm autoantibody response after unilateral vas deferens ligation in rats: when does it develop? J Androl 23:669–673. (1B) Shin D, Lipshultz LI, Goldstein M, Barmé GA, Fuchs EF, Nagler HM, McCallum SW, Niederberger CS, Schoor RA, Brugh VM 3rd, Honig SC (2005) Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia. Ann Surg 241:553–558. (4) Fitzgibbons RJ Jr (2005) Can we be sure polypropylene mesh causes infertility? Ann Surg 241:559–561. (5) Chapter 12: Intraperitoneal onlay mesh (IPOM) for inguinal hernia repair—still a therapeutic option? Kirpal Singh, Maurice E. Arregui Is there any role for intraperitoneal onlay mesh in inguinal hernia repair? Search Items: “IPOM”; “Intraperitoneal onlay Mesh”; “Inguinal hernia” AND “Intraperitoneal” AND “Onlay” AND “mesh” Statements Level 1B Higher recurrence rate with IPOM with longer follow-up. Lower operative times with IPOM technique. Level 4 Fixation may play a significant role. Level 5 Leaving the sac in situ may lead to higher recurrence. Recommendations Grade B IPOM can not be recommended for main stream inguinal hernia repair at this time. Further long-term studies are needed to evaluate true recurrences. Inguinal herniorrhaphy has been evolving since it was first described by Bassini. Lichtenstein popularized tension-free repair with mesh. Laparoscopy arrived on the scene in late 1980s and has further revolutionized the surgical techniques. It is well accepted that laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs have comparable recurrence rates and acceptable morbidity and mortality. Both techniques are challenging and have steep learning curves. The IPOM technique was first introduced in 1991 as a way to reduce or eliminate the difficulty and potential complications of preperitoneal dissection and still maintain the tension free concept . It also is perceived to be faster and easier to perform and teach. The simplicity and reduced operative times are the main attraction of this technique. Unfortunately, there are not many prospective randomized studies with long-term results. There are three randomized trial (1B) [1–4] and one nonrandomized feasibility study  to evaluate IPOM technique. There also are 16 Level 4 case series [6–21]. A study by Vogt et al.  initially showed very good results at 8 months. The recurrence rate for IPOM was 3% compared with 7% for open suture repair. Long-term data were then published by Kingsley et al. . The recurrence rate at 41 months was 43% for IPOM and 15% for open suture repair! This really stresses the importance of long-term follow-up. The IPOM technique was performed with ePTFE mesh (10 × 15 cm2) fenestrated to 1:1.5. Cooper’s ligament was exposed through a small opening and mesh was secured to Cooper’s, the iliopubic tract, and transversus abdominus with EMS Ethicon hernia stapler. The operative times were 62.5 min for IPOM and 80.9 min for the open group. Another study  compared TAPP to IPOM in a prospective, randomized fashion (1B). A total of 76 patients underwent TAPP and 72 underwent IPOM; 10 × 7 cm2 ePTFE was used for IPOM and 15 × 12 cm2 polypropylene mesh was used for TAPP. There were no recurrences in TAPP at 32 months compared with an 11.1% recurrence rate for IPOM. The mesh was tacked with a hernia stapler in both techniques. Neuralgia was noted with 3 TAPP and 11 IPOM patients (p < 0.05). The IPOM technique was faster (53 vs. 71 min, p < 0.001). The strength of this study was that only two surgeons performed all of the operations with reasonable follow-up. The size of the mesh, however, was not standardized! The last Level 1B study  compared IPOM to open tension free repair. Catani randomized 26 patients to IPOM and 24 to open. The IPOM technique used “Gore-Tex DualMesh Plus biomaterial with holes Corduroy” and the open approach utilized Marlex plug and patch. Analgesic requirements were less for IPOM (p < 0.001) and resumption to normal activity was faster with IPOM (8 vs. 17 days, p < 0.001). There were no recurrences with either approach at 12 months. The follow-up is not long enough to draw any strong conclusions from this study. A multicenter feasibility trial was performed by Fitzgibbons et al. . There were 562 patients in TAPP group, 217 patients in IPOM group, and 87 patients in the TEP group. The recurrence rate was 5% for TAPP and IPOM compared with 0% for TEP at an average of 23 months. Polypropylene mesh was used with “appropriate size.” This was tacked using a hernia stapler “like TAPP,” and the sack was left in situ. IPOM had the highest rate of neuralgia. One patient had to have the mesh removed due to inflammatory mass next to the cecum. No fistula was noted, and there was no mention of bowel resection. The investigators concluded that “IPOM should be considered investigation.” Of the 16 Level 4 case series, 10 favored the IPOM technique due to less operative time and acceptable recurrence rate [6–15]. Four of them were against IPOM due to higher recurrence rates or complications [16–19], and two were neutral [20, 21]. Most of the studies had a short and inadequate follow-up. Some of the studies only used a questionnaire rather than physical examinations. More recent studies by Cantani and Olmi have shown more promise with IPOM technique. Catani used Dual GoreTex with Titanium spiral tacs and Olmi used Parietex Composite mesh with fibrin glue. Recurrence rate was 3.3% at an average of 18 months for Catani and 0% at an average of 23.7 months for Olmi. Unfortunately, only 65% of the patients had follow-up at 1 year and only 20% had follow-up at 2 years. This really brings home the point that adequate follow-up is needed before true recurrence rate can be defined for IPOM. Interestingly, Kurukahvecioglu reported a 50-year-old patient with bilateral IPOM with ePTFE repair. The mesh was secured to Cooper’s ligament with small peritoneal incision and to peritoneal surface with tacks. This patient had blood in stool 1 year later and defecated one of the GoreTex mesh. Four years later, he had hematuria and actually urinated four tacks! He had to undergo surgery to remove the GorTex from his bladder. We feel that the IPOM technique is inferior, because mesh is not secured to any substantial fascia. The tacks usually do not penetrate deep into the tissue and there is no posterior fascia. These tacks also can become a source of chronic pain. The hernia sac is left in place and others have noted migration of the mesh into the hernia sac over time (Grade 5). There is a deviation from standard technique of trying to reduce the hernia sac for faster operation. Faster is not always better (Grade 5). There have been case reports of mesh-related bowel and bladder fistulae, which further complicates patient management. We feel that such complications are under-reported. References (in parentheses graduation of evidence) Kingsley D, Vogt DM et al. (1998) Laparoscopic intraperitoneal onlay inguinal herniorrhaphy. Am J Surg 176:548–553. (1B) Vogt DM, Curet MJ et al. (1995) Preliminary results of a prostective randomized trial of laparoscopic onlay versus coventional inguinal herniorrhaphy. Am J Surg 169:84–90. (1B) Sarli L, Pietra N et al. (1997) Laparoscopic hernia repair. Surg Laparosc Endosc 7:472–476. (1B) Catani M, De Milito R et al. (2003) Laparoscopic inguinal hernia repair “IPOM” vs “open tension-free.” Preliminary results of a prospective randomized study. Minerva Chir 58:783. (1B) Fitzgibbons RJ Jr etal (1995) Laparoscopic inguinal herniorrhaphy – results of a multicenter trial. Ann of Surg 221:3–13. (2B) Catani M, Milito R De et al. (2004) Is there a place for intraperitoneal onlay mesh repari (IPOM) of inguinal hernia among laparoscopic techniques? Hepato-Gastroenterology 51:1387–1392. (4) Olmi S, Scaini A et al. (2007) Laparoscopic repair of inguinal hernias using an intraperitoneal only mesh technique and a Parietes composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results. Surg Endosc 21:1961–1964. (4) Chan ACW, Lee TW et al. (1984) Early results of laparoscopic intraperitoneal onlay mesh repair for inguinal hernia. Br J Surg 81:1761–1762. (4) Phillips EH, Rosenthal R et al. (1995) Reasons for early recurrence following laparoscopic hernioplasty. Surg Endosc 9:140–145. (4) Schmidt J, Carbajo MA et al. (2001) Laparoscopic intraperitoneal onlay polytetrafluoroethylene mesh repair (IPOM) for inguinal hernia during spinal anesthesia in patients with severe medical conditions. Surg Laparosc Endosc Percutan Tech 11:34–37. (4) Carbajo MA, Martin JC et al. (1999) Laparoscopic inguinal hernioplasty with PTFE mesh. Personal technique and results. Hernia 3:99. (4) Toy FK, Moskowitz M et al. (1996) Results of a prospective multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty. J Laparoendosc Surg 6:375–386. (4) Czudec S, Mec V (2001) Comparison of TAPP and IPOM method in laparoscopic inguinal hernia repair. Hernia 5:S60. (4) Almedia JA, Franklin ME et al. (2001) Laparoscopic intraperitoneal onlay mesh hernioplasty. Hernia 5:S54. (4) Gillion JF, Balique JC et al. (1996) Celioscopic treatment of recurrence of inguinal hernia after insertion of a prosthesis. Value of the interperitoneal technique with ePTFE patch? Group CHIC (Cure des Heries Inguino-crurales sous Coelioscopie). Ann Surg 50:821–826. (4) Memon MA, Fitzgibbons RJ Jr et al. (1990) Laparoscopic repair of recurrent hernias. Surg Endosc 13:807–810. (4) Kurukahvecioglu O, Ege B et al. (2007) Polytetrafluoroethylene prosthesis migration into the bladder after laparoscopic hernia repair. Surg Laparosc Endosc Percutan Tech 17: 474–476. (4) Filipi CJ, Fitzgibbons RJ Jr et al. (1992) Laparoscopic herniorrhapy. Surg Clin N Am 72: 1109–1124. (4) Blanc P, Porcheron J et al. (1999) Results of laparoscopic hernioplasty. A study of 401 cases in 318 patients. Chirurgie 124:412–418. (4) Hatzitheofilou C, Lakhoo M et al. (1997) Laparoscopic inguinal hernia repair by an intraperitoneal onlay mesh technique using expanded PTFE. Surg Laparosc Endosc 7:451–455. (4) Toy FK, Smoot RT (1991) Toy-Smoot laparoscopic hernioplasty. Surg Laparosc Endosc 1:151–155. (4) Chapter 13: Role for open preperitoneal mesh placement in the era of laparoscopic inguinal hernia repair Kirpal Singh, Maurice E. Arregui What is the role of open preperitoneal hernia repair in the era of laparasoscopic inguinal hernia repair? Search terms: “open preperitoneal hernia repair”; “laparoscopic inguinal hernia repair”; “TAPP” AND “preperitoneal” AND “hernia repair”; “TEP” AND “preperitoneal” AND “hernia repair”; “preperitoneal” AND “hernia” AND “repair” Statements Level 1A Laparoscopic approaches have fewer local complications. Laparoscopic approaches have less pain. Laparoscopic approaches have faster return to normal activities. Laparoscopic approaches have lower morbidities. Level 1B Laparoscopic approaches have longer operative times. Laparoscopic approaches have less pain and faster return to normal activity and work. Level 5 Minimally invasive open approaches (i.e., Kugel) have limited visualization and higher likely hood of injury or incomplete dissection. Both anterior and posterior spaces are violated leading to difficult reoperative surgery. Recommendations Grade B Laparoscopic approach is recommended over open preperitoneal due to less morbidity, less pain, and faster recovery. Grade D Open approach may be considered in patients with recurrent hernia and inability to undergo general anesthesia. The approach to inguinal hernia has been evolving since Bassini first described it. There are proponents of open anterior tissue repairs (Shouldice), open preperitoneal repairs, open anterior repairs with mesh, and laparoscopic repairs with mesh, including TAPP (laparoscopic transabdominal preperitoneal repair) and TEP (laparoscopic totally extraperitoneal repair). Many different open preperitoneal approaches have been described, making it difficult to summarize and compare them with laparoscopic approaches. Two Level 1A studies concluded that endoscopic repairs do have advantages in terms of local complications, pain-associated parameters, and faster return to normal activities; however, “Well structured trials with improved standardization of hernia type, operative technique, and surgeons’ experience are necessary” [1, 2]. Both of these studies were reviewed by the Database of Abstracts of Reviews of Effects in 2008. It was concluded that “overall methodological quality of the studies was poor and limited the conclusions that could be drawn.” However, laparoscopic hernia repairs did have less postoperative pain and faster return to normal activities. The five Level 1B studies have been outlined in Table 1 and overall are in favor of laparoscopic approaches due to less pain and faster return to normal activity [3–7]. Champault et al.  compared 51 patients with TEP to 49 patients with Stoppa. They noted a 6% recurrence rate with TEP and 2% with Stoppa repair, although the mesh used for TEP was smaller (11 × 6 vs. 12 × 15 cm2). Morbidity was only 4% with TEP compared with 30% with Stoppa (p = 0.01). TEP also had less pain and a faster recovery with statistical significance. Table 1 Level 1B studies Study Date Type of repair No. of patients F/U (months) OR time Pain LOS Return to nl/work Recurrence Morbidity Notes Champault et al.  1997 TEP vs. Stoppa 100 pts w primary andrecurrent hernias 93% @ 36 months Longer for b/l and Recurr in TEP Less in TEP (p = 0.0001 VAS) 3.2 days (TEP) vs. 7.3 days (p = 0.01) 11 days (TEP) vs. 17 days (p = 0.01) 6% (TEP) vs. 2% Stoppa 4% (TEP) vs. 29.5% (p = 0.01) Higher RR with smaller Mesh (11 × 6 cm2. No diff in RR with Mesh size of 15 × 12 cm2 Beets et al.  1999 TAPP vs. GPRVS 79 pts w 93 recurrent and 15 primary hernias 34 months 79 min (TAPP) vs. 56 min Less in TAPP (p = 0.05) 92.5% in TAPP vs. 77% in GPRVS–same day 13 days (TAPP) vs. 23 days (p = 0.03) 12.5% (TAPP) vs. 1.9% (p = 0.04) 0 (TAPP) vs. 4 pts (p = 0.04) with infection despite abx in GPRVS pts TAPP group had 52 recurrent hernias in 42 pts vs. 41 recurrent hernias in 37 pts Aitola et al.  1998 TAPP vs. open preperitoneal 49 pts w Uni, bilateral and recurrent 18 months 66 min (TAPP) vs. 55 min (p < 0.01) Less in TAPP (p < 0.01 for movement and p < 0.05 for coughing) N/A 7 days (TAPP) vs. 5 days (open) 13% (TAPP) vs. 8% (open) 21% (TAPP) vs. 8% Concluded open is better due to less cost, higher RR, and no benefit with return to nl activity, although twice as many pts with recurrence and b/l hernias in TAPP. Johansson et al.  1999 TAPP vs. open preperitoneal vs. conventional 613 pts 12 months 65 min (TAPP) vs. 38 min (open) vs. 37 min Less with TAPP @ 8 weeks compared with open (p = 0.02) N/A (“mainly out-patient”) 14.7 days (TAPP) vs. 17.7 days (open) vs. 17.9 days (p = 0.05) 4 pts (TAPP) vs. 11 pts (open) vs. 4 pts N/A Most of the TAPP recurrences were early, i.e., technical Simmermacher et al.  2000 TEP vs. Grid-Iron 162 pts w primary unilateral hernias N/A 39 min (TEP) vs. 27 min (p < 0.001) Same Same Same N/A 13 pts w 6 conversion to open (TEP) vs. 8 pts Concluded that open is better due to less OR time, higher OR complications, and able to handle bleeding/tear with the same incision in open approach. But No F/U and NO RR. TAPP transabdominal preperitoneal patch plasty; GPRVS great prosthetic replacement of the visceral sac; TEP total extraperitoneal patch plasty; nl normal; LOS length of stay; pts patients; F/U follow-up Beets et al.  compared TAPP with GPRVS (great prosthetic replacement of the visceral sac). There was a difference in size of the mesh but not far from what is utilized now (10 × 15 vs. 18 × 26 cm2). The open operation was faster (56 vs. 79 min; p = 0.001). There were no wound infections in TAPP compared with four with the open (p = 0.04). The recurrence rate was higher for TAPP (12.5 vs. 1.9%), but there was “variable degree of experience with the TAPP approach, and all surgeons had performed less than 50 cases. The TAPP group was able to be discharged same day in 93% of the cases compared with 77% with open. Interestingly, the cost of surgery was comparable in both goups ($1,179 for TAPP and $1,150 for open). Aitola et al.  compared TAPP with open preperitoneal approach (opening the transversalis fascia from internal ring to pubic tubercle and suturing 6 × 12 cm2 Marlex mesh to Cooper’s, rectus, and Transversalis fascia). There were 24 patients in TAPP and 25 in the open group. Interestingly, there were twice as many patients with recurrent hernia in TAPP group. The open group was faster (55 vs. 66 min, p < 0.01), but pain was less in TAPP group (p < 0.01). The recurrence rate was 13% with TAPP and 8% with open. They concluded that open is better due to less cost and lower recurrence rate. The size of the mesh was small in this series and the method chosen to secure the mesh was different (sutures vs. staples). The staples do not go as deep as the sutures are able. Johansson et al.  compared TAPP to open preperitoneal (split incision) to conventional (suture only). Follow-up was 1 year and most of the TAPP recurred in 6 months, indicating technical failure. Also, the open approach used sutures compared with tacks for TAPP. Simmermacher et al.  studied TEP compared with the Grid-Iron (Ugahary) approach. The open approach was faster. There were no differences in pain and return back to work. However, the major limitation of this study is that there was no follow-up period and no recurrence rate mentioned. There were six Level 2B studies but only three of these directly compared the laparoscopic to open surgeries. Mok et al.  compared TAPP with the Nyhus repair for recurrent inguinal hernia repairs. The size of mesh was 8 × 12 for TAPP but not mentioned for the open approach. There was less pain with TAPP (p < 0.01) and faster return to work (14 vs. 28 days, p < 0.01). Despite the smaller mesh, the recurrence rate was only 1% at 54 months. TAPP cost $615 more. Goodwin and Traverso  compared TAPP with open periperitoneal (PPO). PPO took less time and had lower cost ($1,343 vs. $2,176, p < 0.001). Size of mesh was 6 × 12 cm2 for TAPP and 6 × 10 cm2for PPO. There was one recurrence at 5 months, indicating technical failure. There was higher morbidity with TAPP compared with PPO. Follow-up was done by mail and averaged 7 months for PPO and 22 months for TAPP. Velasco et al.  compared TAPP to the Stoppa repair. Both were stapled and TAPP was noted to be $500 more. TAPP patients stayed in the hospital for 4 h compared with 48 h. Recurrence rate was not different (approximately 6%). TAPP patients resumed normal activity in 9 days compared with 22 days for Stoppa. The other three studies did not compare the open preperitoneal approach to laparoscopy. All favored the open perperitoneal approach: Nieuwenhove et al.  studied only Kugel (five times more expensive than regular mesh) but with 3.5% persistent pain; Reddy et al.  were in favor of Kugel but with 2.8% dull ache at 1 year without treatment; Kurzer et al.  studied the Stoppa or Wantz repair for recurrent hernias with 5% RR at 4 years. The ten Level 4 studies showed nine for open approach and one against open preperitoneal approach [14–23]. The majority of these studies had short follow-up, and there was much heterogeneity. References (in parentheses graduation of evidence) Schmedt CG, Sauerland S, Bittner R (2005) Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair. Surg Endosc 19:188–199. (1A) Cheek CM, Black NA et al. (1998) Groin hernia surgery: a systematic review. Ann R Coll Surg Engl 80(Suppl 1):S1–S80. (1A) Champault GG, Rizk N et al. (1997) Inguinal hernia repair. Totally preperitoneal laparoscopic approach versus Stoppa operation: randomized trial of 100 cases. Surg Laparosc Endosc 7:445–450. (1B) Beets GL, Dirksen CD et al. (1999) Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia? A randomized controlled trial. Surg Endosc Ultrasound Intervent Tech 13:323–327. (1B) Aitola P, Airo I, Matikainen M (1998) Laparoscopic versus open preperitoneal inguinal hernia repair: a prospective randomized trial. Ann Chirurgiae Gynaecol 87:22–25. (1B) Johansson B, Hallerback B et al. (1999) Laparoscopic mesh versus open preperitoneal mesh versus conventional technique for inguinal hernia repair. Ann of Surg 230:225–231. (1B) Simmermacher RKJ, Clevers GJ et al. (2000) Preperitoneal mesh in groin hernia surgery. A randomized clinical trial emphasizing the surgical aspects of preperitoneal placement via a laparoscopic (TEP) or Grid-iron (Ugahary) approach. Hernia. 4:296–298. (1B) Mok KT, Wang BW et al. (1998) Laparoscopic versus open preperitoneal prosthetic herniorrhaphy for recurrent inguinal hernia. Int Surg 83:174–176. (2B) Goodwin JS II, Traverso LW (1995) A prospective cost and outcome comparison of inguinal hernia repairs. Surg Endosc 9:981–983. (2B) Velasco JM, Gelman C, Vallina VL (1996) Preperitoneal bilateral inguinal herniorrhaphy. Surg Endosc 10:122–127. (2B) Nieuwenhove YV, Vansteenkiste F et al. (2007) Open, preperitoneal hernia repair with the Kugel patch: a prospective multicenter study of 450 repairs. Hernia 11:9–13. (2B) Reddy KM Humphreys W, Chew A, Toouli J (2005) Inguinal hernia repair with the Kugel Patch. ANZ J Surg 75:43–47. (2B) Kurzer M, Belsham PA, Kark AE (2002) Prospective study of open preperitoneal mesh repair for recurrent inguinal hernia. Br J Surg 89:90–93. (2B) Kugel RD (2003) The Kugel repair for groin hernias. Surg Clin N Am 83:1119–1139. (4) Baroody M, Bansal V, Maish G (2004) The open preperitoneal approach to recurrent inguinal hernias in high-risk patients. Hernia 8:373–375. (4) Hoste W, Nieuwenhove YV, Vierendeels T (2006) Early Belgian experience with the Kugel patch inguinal hernia repair. Acta Chir Belg 106:44–46. (4) Fenoglio ME, Bermas HR et al. (2005) Inguinal hernia repair: results using an open prepritoneal approach. Hernia 9:160–161. (4) Ceriani V, Faleschini E, Sarli D et al. (2005) Kugel hernia repair: open “mini-invasive” technique. Personal experience on 620 patients. Hernia 9:344–347. (4) Horton MD, Florence MG (1993) Simplified preperitoneal marlex hernia repair. Am J Surg 165:595–599. (4) Schroder DM, Lloyd LR et al. (2004) Inguinal hernia recurrence following preperitoneal Kugel patch repair. Am Surg 70:132–136. (4) Farooq O et al. (2005) Recurrent inguinal hernia repair by open preperitoneal approach. JCPSP 15:261–265. (4) Kugel RD (1999) Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless, inguinal herniorrhaphy. Am J Surg 178:298–302. (4) Ugahary F, Simmermacher RKJ (1998) Groin hernia repair via a grid-iron incision: an alternative technique for preperitoneal mesh insertion. Hernia 2:123–125. (4) Chapter 14: Sportsman hernia—diagnosis and treatment Moshe Dudai/Salvador Morales-Conde, Reinhard Bittner Tel Aviv, Israel/Salvador Morales-Conde, Sevilla (Spain), Stuttgart, Germany Search terms To write the guideline recommendations for the Sportsman Hernia (SH), a literature search was conducted in PubMed and Medline through the years 1990–2008 using the terms: Sportsmen Hernia, Sport Hernia, Athletes Hernia, Athletes Pubalgia, Groin Injury/Treatment, Surgery, Technique, Repair, Surgical finding, Pathology, Diagnosis, Etiology, Results, Complications Of the 127 articles found, 66 are relevant, but only 13 with a level of evidence better than 4: 1 Level 1B, 2 Level 2B, 4 Level 3A, 6 Level 3B, 43 Level 4, 10 Level 5 (review articles). The four systematic reviews of the literature were assigned Level 3A, because all but three studies analyzed were only Level 4. Definition and differential diagnosis Statements Level 3A Chronic pain (longstanding groin pain–LSGP) is a leading cause of athletes’ retirement from competitive sports. Chronic pain in athletes is an obscure condition of uncertain etiology commonly seen in soccer, football, rugby, and ice hockey players. At a high level of play, teams have significantly higher risk of injury than teams at a lower level. Physical examination reveals no detectable inguinal hernia. The differential diagnosis is difficult to make from physical examination and is thus largely established only at the time of surgery. Although there are several reports of chronic pain in women, it is almost exclusively found in men. Level 4 Chronic pain is a challenging problem among not only athletes but also the general population. In the majority of athletic maneuvers, a tremendous amount of torque or twisting occurs in the midportion of the body, and the front or anterior portion of the pelvis accounts for the majority of the force. The main muscles inserting at or near the pubis are the rectus abdominis muscle, which combines with the transversus abdominis. Across from these muscles, and directly opposing their forces, is the abductor longus. The opposing forces of the muscles at their insertion site on the pubis cause a disruption of the muscle/tendon, causing chronic pain related to the fact that forces are excessive and imbalanced, leading to an increase of the weakness of the posterior wall of the groin or to a pubic bone stress injury (PBSI), which may lead to degenerative arthropathy of the pubic symphysis in advanced stages. Chronic groin pain in athletes is mainly caused by two different pathologic entities: the sportsman hernia (SH) or the athletes pubalgia due to a pubic bone stress injury (PBSI). PBSI include entities, such us tendon enthesitis, pubic osteitis, or avulsion fractures. In SH, the likely causative factor is a posterior wall deficiency (PWD). Entrapment of inguinal nerves may create symptoms that resemble those of a sports hernia. The sports hernia is one of the least understood, poorly defined, and under-researched maladies to affect the human body  and is a leading cause of athletes’ retirement from competitive sports [44, 45]. It is more common in high-level athletes . It is an obscure condition of uncertain etiology commonly seen in soccer, football, rugby, and ice hockey players [9, 17, 58]. It reflects a compilation of diagnoses grouped together with a wide range of other pathologies that need to be excluded before this should be considered as a diagnosis . The etiology, onset, anatomy involved, and terminology used to define it vary widely in the literature [9, 58]. The precise sequence of events that lead to its development is not well known, but the combination of abdominal and hip adductor muscle strength, endurance and coordination imbalances, lumbopelvic and hip rotation range of motion deficits, poor tissue extensibility, and intense or high-repetition hip adductor muscle shearing forces through their pelvic attachments may be the primary factors [9, 17, 27, 44, 51, 61]. Some authors emphasize inguinal nerve compression (entrapment) as a cause of chronic pain in athletes produced by direct trauma or overzealous training and hypertrophy of abdominal musculature [2, 23, 43, 53, 63]. The phrase “groin disruption” was popularized by Gilmore for sport injuries followed by chronic pain in the groin and abdominal muscles area with no findings of hernia, but inguinal wall and superficial inguinal ring disorders caused by injuries to the internal oblique aponeurosis, conjoined tendon-pubic tubercle attachment and dehiscence between the tendon-inguinal ligament. He successfully advised a surgical technique for treatment based on modifications of the historic Bassini operation [20, 21]. Gilmore, as well as others, found that the pain is caused by posterior wall deficiency (PWD) as a result of trauma to the tranversalis fascia or conjoint tendon, which is formed by the medial portion of internal oblique and transversus abdominis muscle [2, 12, 22, 47]. Nevertheless, many uncertainties remain, not the least due to the existence of other pathologies around the symphysis pubis, which were in some way easier to diagnose. Diagnostic imaging is useful to exclude other conditions  but does not generally reveal a sports hernia. With time, especially after the introduction of laparoscopy, the understanding of the different pathologies and pathogenetic mechanisms has improved. Today, posterior inguinal wall insufficiency that creates an occult hernia that is not apparent on physical examination is recognized as the most common surgical finding . For this reason, the pathological definition of PWD was accepted as equivalent to the pathology of SH, and confirmed by multiple studies [17, 47, 52, 58]. From an anatomical point of view, the definition and the name of this entity should be reviewed. Confusion related to “sportsmen hernia” often arises from the complex anatomy and biomechanics of the symphysis region, from the large number of potential sources of groin pain, and from the similarity of symptoms in athletes with different sites of injuries. There are different anatomic areas to be considered when we talk about this entity, including ligaments, tendons, nerves, muscles, and bones. In the majority of athletic maneuvers, a tremendous amount of torque or twisting occurs in the midportion of the body, and the front or anterior portion of the pelvis accounts for the majority of the force. The main muscles inserting at or near the pubis are the rectus abdominis muscle, which combines with the transversus abdominis. Across from these muscles, and directly opposing their forces, is the abductor longus. These opposing forces cause a disruption of the muscle/tendon at their insertion site on the pubis, so the problem could be related to the fact that forces are excessive and imbalanced, and a weak area at the groin could be increased due to the forces produced by the muscles. The forces produced by these muscles may be imbalanced and could produce a disruption of the muscle/tendon at their insertion site on the pubis or/and a weak area may be increased due to the forces produced by the muscles; just this last possibility could be defined as sportsmen hernia. On the other hand, this disruption of the muscle/tendon at their insertion site could be defined as a PBSI (pubic bone stress injury), which affects not only the pubic bone itself but also the muscles and their tendons on both sides of the symphysis pubis . (In the past, it was mistakenly referred to as osteitis pubis.) For that reason, this term could include different entities, such as tendon enthesitis, pubic osteitis, or avulsion fractures. In conclusion, this global entity could be considered an imbalance of the muscles (abductor and abdominal) at the pubis, which leads to an increase of the weakness of the posterior wall of the groin and produces a tendon enthesitis. Once a true origin is not detected, because, for example, a hernia is a hernia or a nerve entrapment is a nerve entrapment, etc., that may lead to a degenerative arthropathy of the pubic symphyses in the advanced stages. Based on this, this entity could be renamed, “syndrome of muscle imbalance of the groin,” and the sportsmen hernia could be considered an entity included in this syndrome (Table 1). Table 1 History Statements Level 4 Groin pain starts during extreme sport activity, usually with no proper buildup of durability, acceleration, deceleration, and rotation. Pain responds to conservative treatment, anti-inflammatory drugs, and rest. Pain typically recurs at the resumption of sport activity. Diagnostic procedures Statements Level 2B In patients with chronic groin pain and clinically uncertain herniations, magnetic resonance imaging (MRI) and ultrasound (US) are valid diagnostic tools. Level 3B Ultrasound is a useful adjunct diagnostic tool, not only to evaluate the groin for hernias, with high overall accuracy, but also in SH to identify inguinal canal posterior wall deficiency in young men with no clinical signs of hernia with chronic groin pain. Level 4 The management of groin injuries demands the recruitment of a team with experience with different aspects of groin pain. Both the history and quality of symptoms and the physical examination may help to differentiate between SH and TE. History of chronic groin pain that is nonresponsive to conservative treatment should raise suspicion of SH. MRI appears to have excellent diagnostic potential for assessing various causes of long-standing groin pain (LSGP) in athletes. MRI may not be a useful tool for deciding between operative or conservative treatment. MRI is a valuable tool to monitor the alterations with reference to their response to conservative treatment, which alos may help the athletes to return to their activities. Dynamic ultrasound shows promising results in accurately diagnosing SH. In selected cases, laparoscopic inguinal exploration may be helpful. Essentially, it is a diagnosis that can only be confirmed at surgery. Recommendations Grade 3A Comprehensive physical examination that requires excluding numerous other musculoskeletal and nonmuscoloskeletal conditions is mandatory. Plain radiography, ultrasonography, and scintigraphy should be the first-line investigations to supplement clinical investigation. The cost of computed tomography and magnetic resonance imaging are such that their routine use for assessment of patients with groin pain cannot be justified. They may, however, be employed in difficult cases to help define the anatomical extent of a groin injury. Dynamic ultrasound may be able to replace historical inguinal herniography. Grade 4 In unclear cases with some suspicion of posterior wall deficiency, surgical exploration should be performed. Gradual physical therapy combined with pharmacotherapy should be effective in most cases and should be part of the diagnosis process. Diagnosis of chronic groin pain is difficult, but early diagnosis is very important because morbidity will be reduced. These groin injuries are some of the most challenging injuries in the field of sports medicine, and the literature provides no consensus on definitions of diagnostic criteria for groin pain in athletes . The combination of complex anatomy , variability of presentation, and the nonspecific nature of the signs and symptoms make the diagnostic process problematical. Therefore, management of groin injuries can be challenging, and diagnosis can be difficult because of the degree of overlap of symptoms between the different problems . This clinical setting demands the recruitment of a team with experience of different aspects of groin pain. Ekberg et al.  have established a multidisciplinary investigation to reveal the underlying cause. These examinations included general surgeons for detection of inguinal hernia and neuralgia, orthopedic surgeons for detection of adductor tenoperiostitis and symphysitis, urologist for detection of prostatitis, radiologist for performing different imaging tests, and nuclear medicine for isotope studies. For these reasons, the so-called SH is largely a clinical diagnosis of exclusion . SH must be distinguished from the more common osteitis pubis and musculotendinous injuries . The first step is to determine the differential diagnosis of hip and groin pain with respect to the high frequency of referred pain from the lumbar spine, lower abdomen, and pelvis , which is very difficult in some cases. A systematic approach to the hip and groin area is important to identify the origin of pain. Both the history and quality of symptoms and the physical examination are the basics of the diagnostic algorithm. In some cases, the diagnostic workup with roentgenograms and possibly an injection with a local anesthetic to the suspected origin of pain are completed . There are clinical signs for the diagnosis of nerve pathologies, such us obturator neuropathies. These patients usually have clinical symptoms and signs of postexercise groin, lower abdominal or medial tight pain, and adductor muscles weakness and paresthesia in cutaneous distribution of medial thigh. Except clinical signs in the diagnosis of obturator neuropathy diagnostic local anesthetic block and electromyography have been used . History of chronic groin pain that is nonresponsive to treatment should raise suspicion of SH [1, 17, 39]; however, physical examination findings are subtle and most diagnostic tests do not definitively confirm the diagnosis . Traditional physiotherapy of isometric active weight-bearing exercise will result in complete healing of almost all athletes [24, 47]. It is important to highlight that adductor strain is a possible part of this pathological syndrome and therefore tenotomy should not be performed under any circumstances . Finally, in selected cases, correct diagnosis is only possible with diagnostic laparoscopy [17, 57]. Physical examination Physical examination is the first step in the diagnosis of groin pain, although symptoms often are vague and diffuse . When active, sportsmen start to feel a dull pain in the groin region. A deep palpation above the inguinal canal will find the area to be sensitive and the external inguinal ring dilated . In a digital examination of the canal, a soft bulge can be felt against the tip of the finger and extreme sensitivity to pressure applied with the tip of the finger against the floor of the canal where the genito-femoral nerve passes. With this syndrome, the nerve is entrapped under the IPT (ileo-pubic tract) in the internal inguinal ring area [2, 43]. In addition, all of the symptoms increase during coughing. The clinical assessment of groin pain in athletes is difficult; the lack of specific clinical tests is in part responsible. The examinations could include evaluation of adductor muscle-related pain and strength, iliopsoas muscle-related pain, strength, and flexibility, abdominal muscle-related pain, and strength and pain at the symphysis joint, but the only test without acceptable interobserver reliability was the strength test for iliopsoas muscle . Gradual physical therapy combined with pharmacotherapy should be effective in most cases and should be part of the diagnosis process. This process includes nonsteroid anti-inflammatory drugs and muscle relaxants. A physical therapy program usually involves stretching and strengthening of adductor muscles, abdominal wall muscles, iliopsoas muscle, quadriceps, and hamstrings. If physical therapy and pharmacotherapy fail, different tests should be performed. Ultrasound Ultrasound is a useful adjunct to evaluate the groin for hernia. The overall accuracy in finding a hernia of any kind by ultrasound is 92%. On the other hand, this imaging test identifies the pathology in a groin without a palpable bulge at an accuracy of 75% . Ultrasound, which enables a dynamic assessment, is particularly useful in these patients [7, 9, 17, 49]. Dynamic ultrasound examination is able to detect inguinal canal posterior wall deficiency in young men with no clinical signs of hernia with chronic groin pain. As the patient actively strains during the investigation, a real-time convex anterior bulge and ballooning of the inguinal canal can be observed at the superficial inguinal ring. This examination has been proposed to be performed with the patient in the supine and erect positions, in a relaxed state, as well as during coughing and during Valsalva maneuver . Orchard et al.  have shown a correlation between bilateral deficiency of the posterior wall and groin pain, although the temporal relationship between the clinical and ultrasound findings was not established by this study. Depasquale et al.  also have shown that ultrasound is a useful tool for identifying hernias, and therefore, aids surgical management; 39% (n = 94) of the patients examined who had groin pain were positive for hernias. Only four false-positive were found of the 62 who underwent surgery, giving a positive predictive value of 94% in operated patients. Not seldom, a preperitoneal lipoma herniating into the inner inguinal ring and canal or the obturator canal can be demonstrated by ultrasound. Evidence of genito-femoral nerve entrapment can be shown by edema behind the IPT on the level of internal inguinal ring. In some cases, tears and strain of the conjoint tendon in its insertion to the pubis can be seen. Even though some authors still advocate herniography for identifying impalpable herniations causing pain in athletes , today dynamic ultrasound should be the diagnostic tool of first choice. CT scan and MRI CT scan and MRI have been proposed as diagnostic tests for chronic groin pain, but the costs are such that their routine use for assessment of patients with groin pain cannot be justified . Furthermore, MRI is not a useful tool for deciding between operative and conservative treatment . Bone scan, plain radiography, and ultrasound has been used for diagnosing these entities, but MRI appears to be superior [45, 58, 61, 62]. A clinical and imaging diagnosis is crucial, because in PBSI there is no need for surgical intervention. The use of CT scans could help to identify posterior inguinal wall deficiencies and hernias in some cases  and may be employed in difficult cases to help define the anatomical extent of a groin injury . On the other hand, MRI provided an accurate depiction of pubic bone alterations and of adjacent myotendinous structures [6, 52] and also was very useful to determine the presence of inguinal hernias , because allows the direct visualization of the hernial sac within the inguinal canal. Athletes with groin pain and tenderness of the pubic symphysis and/or superior pubic ramus have clinical features consistent with the diagnosis of osteitis pubis. The increased signal intensity seen on MRI is due to pubic bone marrow edema. A stress injury to the pubic bone is the most likely explanation for these MRI findings. MRI can permit an accurate and early diagnosis of the different sport-related pubic conditions and also is a valuable tool for monitoring the alterations with reference to their response to treatment, which may help the athletes return to their activities. It should be considered that abnormal magnetic resonance imaging findings are common in asymptomatic athletes, which decreases the value of magnetic resonance imaging in surgical decision-making . Indication for surgery Statements Level 1B An active physical therapy program designed to strengthen the muscles to stabilize the hip and pelvis has positive effects and leads to earlier return to sports at the same level, and it is superior to a physiotherapy treatment without active training. Level 3A Until now, there has been no evidence-based consensus available to guide decision-making. The methodological quality of the studies available for analysis is low. A single entheseal pubic cleft injection can be expected to afford at least 1 year of relief from adductor-related groin pain in a competitive athlete with normal findings on a magnetic resonance imaging scan. Surgery seems to be more effective than conservative treatment for SH. Good results can be obtained with surgery when posterior inguinal wall deficiency is the sole diagnosis. Information on specific conservative interventions is poorly presented, and well-designed studies are lacking. Level 4 In PBSI, conservative management results more likely in an excellent outcome. In SH, the results of surgical repair to the posterior inguinal wall are excellent. Recommendations Grade B A multidisciplinary approach to groin pain should be adopted. Generally, conservative measures should be tried first, consisting of an initial period of rest or restricted activities, followed by physical therapy designed to stabilize the pelvis and hip. When conservative management has failed, surgical intervention should be done. Grade D Athletes with chronic groin pain and PWD who are unable to compete in active sports should be considered for routine inguinal hernia repair if no other pathology is evident after clinical examination and investigation. Type of surgical procedure Statements Level 3A Both open and laparoscopic surgical approaches have been reported to eliminate symptoms effectively and enable patients to return to previous sporting activity levels. The success rates are very good and comparable between open (92.8%) and laparoscopic (96%) repairs based solely on the criterion of return to sports activity. A wide variety of open repair techniques are described with or without mesh, including repair of a presumed “thin” or damaged insertion of the tendon of the rectus abdominis onto the pubic crest, but there are no data allowing a comparison between these techniques. There is no scientific evidence that an adductor tenotomy is of any additional value. In open repair, ilioinguinal nerve resection seems to be beneficial. Laparoscopic approach may provide better posterior inguinal wall exposure, enabling easier bilateral reinforcement. During surgery, the inguinal canal should be thoroughly explored to find different entities responsible for inguinal pain (preperitoneal lipoma, etc.). Laparoscopic techniques generally enable a quicker recovery time than open techniques. Level 4 Two variations of laparoscopic surgery are applied: the transabdominal preperitoneal patch plasty (TAPP) and the total extraperitoneal patch plasty (TEP); however, no study shows the superiority of one compared with the other. Recommendations Grade C Regarding time of recovery and return to preinjury sports activity levels, laparoscopic surgery—either TAPP or TEP—should be the treatment of choice. Well-designed prospective, randomized, controlled studies are greatly needed to establish the true efficacy of these different surgical approaches. Postsurgical rehabilitation Statements Level 3A A detailed description of postsurgical rehabilitation programs is generally lacking. Level 4 For patients who underwent open repair, overall postsurgical recovery time (based on return to sports activity) was found to be 17.7 weeks compared with 6.1 weeks for laparoscopic repairs. Recommendations Grade 3A Early, sharp, sudden movements after surgery should be avoided, and core and leg musculoskeletal inflexibility, weakness, poor endurance, or poor coordination should be identified and corrected. Grade 4 A gradually progressive 6-week rehabilitation program should be undertaken after both open and laparoscopic repair. Grade 5 Well-designed studies are greatly needed. Chronic groin pain in athletes is a difficult problem that requires a multidisciplinary approach not only to diagnosis but also for treatment planning [4, 58]. Based on previous definitions, if this imbalance of the groin causes a disruption of the muscle/tendon at their insertion site on the pubis, treatment should be based on rest, anti-inflammatory medication, and a proper training program followed by re-evaluation. For that reason, conservative treatment is tried first , but there is no evidence-based consensus available to guide decision-making . If a weak area has been found at the groin due to the forces produced by the muscles, patients should undergo surgical repair of the groin reinforcing the posterior wall with mesh, because if a conjoined tendon is adequately supported by mesh, abductor discomfort almost uniformly resolves with postoperative rehabilitation. Rarely will the abductor require an operative release, tenotomy, or perforation on the pubis. Conservative treatment Much groin pain due to problems related to the musculoskeletal system are a self-limiting disease that can take several months to resolve, and corticosteroid injection can sometimes hasten this rehabilitation process . Traditional conservative treatment has low success rates [9, 39, 47]. Only one RCT could demonstrate that an active physical training program designed to strengthen the muscles to stabilize the hip and pelvis is of advantage for the patient compared with passive measures . Most studies agree that surgical therapy seems to be superior to nonsurgical treatment [9, 14, 17, 23, 28, 36], but there is only one randomized comparison of poor quality . On the other hand, Schilders et al.  has shown the efficiency of a single entheseal pubic cleft injection. This treatment can be expected to afford at least 1 year of relief of adductor-related groin pain in a competitive athlete with normal findings on a magnetic resonance imaging scan; however, it should be employed only as a diagnostic test or short-term treatment for a competitive athlete with evidence of enthesopathy on magnetic resonance imaging. Surgery Conservative treatment of this entity often does not result in resolution of symptoms . In some series, the athletes have received different conservative treatments without success, and the surgical procedures performed in these cases have offered a definitive resolution to this problem . Several surgical approaches are available for the repair of inguinal hernias, but without knowing the true natural history of this disorder, the problem is that it is difficult to know when it is appropriate to have a hernia repaired . Operating is recommended only if conservative therapy, with prolonged rest, fails . It is important to establish that precise diagnose is always preferable before performing a hernia repair in a patient with chronic groin pain. Steele et al.  showed no significant difference in outcome between subjects who had an abnormal ultrasound scan on the symptomatic side and those who had a normal scan. There was a significant difference in outcome between patients who had a bone scan with increased uptake at the symptomatic pubic tubercle and those who did not (p < 0.04). This study supports other research that shows that good results can be obtained with surgery when posterior inguinal wall deficiency is the sole diagnosis. Surgical intervention of hernia repair for chronic groin pain results in pain-free return of full activities in a majority of cases . No consensus view supports any particular surgical procedure for sportsman’s hernia . Various types of operations, based on the variable theories regarding the pathophysiological process, have been developed for the treatment of this syndrome. Some surgeons focus on the external elements of the inguinal canal and repair the external oblique fascia or enforce the groin with the rectus abdominis. Other surgeons perform an inguinal hernia repair procedure, either with sutures or synthetic mesh, performed by an open approach or laparoscopically. Some researchers believe that the problem is in the lower abdominal muscles, or is caused by nerve entrapment, and treat it accordingly. Recent authors compared an open technique (Bassini) and neurotomy of the ileoinguinal nerve applied to patients with a positive herniogram and/or positive nerve block test with athletes who were treated conservatively . Some authors recommend that, in cases where PWD or tear of the posterior inguinal wall are clearly diagnosed, routine inguinal hernia repair should be done without unnecessary delay [17, 42, 46]. Basically, a number of reports have been published that describe different repairs of the posterior inguinal wall deficiency as the main approach for sportman’s hernias with excellent results [19, 22]. During the operation, the inguinal canal should be thoroughly explored to find the different entities that could be detected during surgery, such us a true inguinal hernia, wide internal ring and peritoneal dimple , hernia femoralis , preperitoneal lipoma , hernia obturatoria , prevascular hernia , obvious musculotendinous tear , muscle asymmetry , or a significant bulge in the posterior wall . Even if no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain , although other authors have recommended not using the mesh in these cases . The most common finding in athletes with chronic groin pain was a deficiency of the posterior wall of the inguinal canal . Some authors believe that ilioinguinal nerve resection may be beneficial for patients [7, 15, 30, 37, 52, 66], but the overall quality of most of the studies is low . When the surgical option is selected, either the open or the laparoscopic approach can provide good results [9, 23, 28]. The endoscopic preperitoneal approach the technique was used more during the past year [50, 55, 57, 60], although other authors consider an open hernia repair using mesh, performed as an outpatient procedure with local anesthesia and sedation as the optimal treatment . Ingoldby  performed a comparative nonrandomized study that compared the open and the laparoscopic approach, which showed that the endoscopic repair permits an early return to activity. A wide variety of open repair techniques are described with mesh [1, 5, 24, 56, 59] or without [15, 20–22, 42, 52], including repair of a “thin” or damaged insertion of the tendon of the rectus abdominis onto the pubic crest [44, 45], but there are no data allowing a comparison between these techniques [9, 31]. One author reported good preliminary results for using fibrin glue to secure the mesh and achieve tension-free open inguinal hernia repair in soccer athletes with chronic pain . The laparoscopic approach may provide better posterior inguinal wall exposure, enabling easier bilateral reinforcement  and allow a quicker recovery time than open surgery [9, 23, 28, 58]. Two types of laparoscopic surgery are successfully applied: the transabdominal preperitoneal patch plasty (TAPP) [19, 28, 35, 65], and the total extraperitoneal preperitoneal patch plasty [12, 51, 55, 57, 60]. No studies have shown the true efficacy of these different techniques, thus a recommendation for one or the other method cannot be given and depends on the skill and personal preference of the surgeon involved. Well-designed prospective, randomized, controlled studies are greatly needed for more clarity and more reliable recommendations. The same is true with respect to postsurgical rehabilitation programs. Until now, there has been no general agreement about the best postoperative physical training programme to enable the athletes to return to full sports activity in the shortest time [24, 60]. Valuable studies that have a high level of evidence are urgently needed. 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Several studies attempted to measure the costs of hernia surgery but with doubtful results. It is an extremely difficult task to perform a reliable analysis of costs (for hospital and society), which might be useful for the surgical community. When calculating costs, one key point is that payroll and operating room costs crucially depend on the kind of hospital in which the operation takes place. Furthermore, these costs are predicated on the hospital’s location, the town, region, country, and continent, and last but not least on the surgeon’s skills. To make it simple, there should be the following basic rules (Level 5) to make aiming costs as low as possible: (1) use the equipment (video tower) for other laparoscopic procedures; (2) use nondisposable trocars and instruments; (3) use a cost-effective mesh (see Chapter “Selection of mesh materials”); (4) perform a lot of operations; (5) perform in a high-quality; and (6) do it in a reasonable time. In conclusion, a strictly standardized technique and perioperative management according to the presented Guidelines of the International Endohernia Society (IEHS) are indispensable requirements for performing a cost-efficient laparoscopic hernia repair. Guidelines Committee Members Maurice Arregui, Department Chair, General Surgery, St. Vincent Hospital, Indianapolis, Indiana, USA. Rene Fortelny, Univ.-Lector. Chief Resident, 2nd Department of Surgery, Wilhelminenspital, Vienna, Austria. Uwe Klinge, Institut for Applied Medical Engineering AME Helmholtz, Aachen, Germany. Davide Lomanto, Director of the Minimally Invasive Surgical Center; Director of the KTP Advanced Surgical Training Center; YYL School of Medicine, National University of Singapore. Jacob Rosenberg, Chief Surgeon, Department of Surgery D, Herlev Hospital, University of Copenhagen, Denmark. Stefan Sauerland, Head of the Department of Non-Drug Interventions, Institute for Quality and Efficiency in Healthcare, Cologne, Germany. Christine Schug-Pass, Department for Surgery, Center for Minimally Invasive Surgery, Vivantes Klinikum Spandau, Berlin, Germany. Michael Timoney, Attending Surgeon/Director of Quality Assurance, Lutherian Medical Center, Brooklyn, NY, USA.