Since Bassini in 1887 published his original description of inguinal hernia repair, many modern modifications such as the Shouldice repair and the Lichtenstein “tensionless” mesh repair had originated from it. Within less than a decade in the 1990’s, laparoscopic enthusiasts had already described three forms of laparoscopic repairs- the intraperitoneal mesh (IPOM) repair, the transabdominal preperitoneal repair (TAPP), and the totally extraperitoneal (TEP) repair.  Laparoscopic hernia surgery has been gaining in popularity in recent years. Several randomized controlled trials and systematic reviews, which compared laparoscopic repair to open repairs, showed that laparoscopy gave the following benefits: a) less postoperative pain, less analgesic consumption, earlier return to normal activities and work in the early postoperative period, b) less long term complications of groin pain and permanent paraesthesia, and c) fewer recurrences than sutured herniorrhaphy, but with comparable efficacy to open mesh repairs.  The endoscopic totally extraperitoneal inguinal hernia repair (TEP) does not enter the peritoneal cavity, reduces the risk of visceral injury, adhesion formation, and the development of port site hernias. It gives comparable results to other forms of laparoscopic repair, and for these reasons, it has become the preferred technique of laparoscopic repair of inguinal hernias.

A review was undertaken of 160 consecutive patients who underwent TEP for inguinal hernia between 1998 and 2003 at the National University Hospital, Singapore. The 160 patients had 200 hernia repairs (120 unilateral and 40 bilateral hernias). The mean age was 51 years and 95% were men. The overall mean operative duration was 70 minutes; bilateral repairs took 27% longer than unilateral repairs. Four patients had conversion to open surgery, and 10 patients developed minor complications (groin seroma). Seven patients (3%) developed hernia recurrence, but there was no recurrence detected in the last 52% of cases. The recurrence rate was higher when the mesh was not anchored (5 of 41 patients; 12%) than when the mesh was anchored (2 of 119 cases; 1.6%). The mean inpatient hospital stay was 1.4 days, and of the last 30 cases, 70% were performed as outpatient.

Laparoscopic inguinal hernia repair is a relatively new approach in the long history of groin hernia repair. However, it has been shown that the laparoscopic approach remains an alternative and feasible method to open hernia surgery. In our prospective and consecutive series over 6 years that TEP hernia repair can be achieved with minimum morbidity and the majority of cases can indeed be performed in the Day Surgery setting, that a learning curve has to be overcome, and the repair can be accomplished with acceptable recurrence rates. The results from this series are comparable to other reports of endoscopic hernia repair. Large trials, mostly of subjects with primary and unilateral inguinal hernia, have shown that operative duration ranged from 30 to 70 minutes, and recurrence rates ranged from 1.9% to 6%. When compared to open surgery, laparoscopy results in less wound complications, less postoperative pain, reduced analgesic requirements, faster resumption of normal activities, and lowered overall cost when hospital and economic productivity costs are considered together, even though equipment costs are higher. The endoscopic approach can be offered to patients with bilateral hernias, where repairs on both sides can be accomplished through the same wounds, and to those with recurrent hernia from previous open repairs, where no adhesions are encountered in the extraperitoneal space. The TEP has clear advantages for both situations, as recommended by the National Institute for Clinical Excellence (NICE). However, patients with primary, unilateral hernia who require rapid recovery from surgery to resume normal activities and work can also benefit from endoscopic repair. Early forms of laparoscopic repairs, such as IPOM, enter the peritoneal cavity to secure the mesh over the inguinal floor. However, intestinal obstruction may result from bowel that inadvertently becomes adherent to the exposed mesh; clearly an undesirable complication. TEP has the advantage of being extraperitoneal, thus minimizing the risk of visceral injury and adhesion formation. The laparoscopic approach also significantly reduces long-term morbidity of permanent paraesthesia or groin pain, compared to open surgery (5% vs. 33%) in a recent trial of 400 patients. Our results show that 135 patients (96%) have their hernia repaired effectively and most are now having their surgery as an outpatient.

The learning curve for endoscopic hernia repair is one reason why most general surgeons still favor open hernia surgery. The learning curve seems steep; more so for non-laparoscopic surgeons than for dedicated laparoscopic surgeons. This may be because: the anatomy of the inguinal region has to be re-learnt from a laparoscopic viewpoint, i.e. from an interior view rather than the exterior approach as is taught in medical school and surgical training, it is more difficult to operate in a confined extraperitoneal space than it is in the abdomen or thorax and, regular practice is needed for endoscopic techniques of mesh placement and orientation. Reports have described placing a large piece of mesh over the inguinal floor without fixation. This reduces cost and prevents occasional impingement of nerves by the tackers. However, in our series, recurrences were significantly higher when the mesh was not fixed. Such recurrences could be explained by mesh migration, mesh in folding or shrinkage. We therefore favour mesh fixation as it results in less hernia recurrence.

In conclusion, endoscopic extraperitoneal hernia repair when performed by an experienced surgeon offers the appropriate patient a viable alternative to open surgery. We recommend that initial cases should be performed under the guidance of a skilled surgeon to overcome the learning curve, and that the mesh should be anchored to the inguinal floor to prevent hernia recurrence.