Mark A Talamini Chandrakanth

Laparoscopy has come a long way since 1901, when George Kelling first performed this procedure to examine the abdominal cavity of a live dog using a Nitze cytoscope.1 ' The credit for Introducing laparoscopy to the United States goes to Bertram M. Bernheim from The Johns Hopkins Medical School.1 ' Calling It "organoscopy," Bernheim performed the procedure on two patients using a proctoscope. One had a carcinoma of the pancreas and was a patient of William S. Halsted. Although the initial half of the twentieth century saw only minor advances, the latter half saw rapid progress, especially in the last 20 years. Despite the advances and successes realized by gynecologists, general surgeons were slow to appreciate the importance of laparoscopy. However, success of laparoscopic cholecystectomy led to the application of

laparoscopy to many other procedures. A natural point of focus was the most commonly performed general surgical procedure, herniorrhaphy. With more than 700,000 herniorrhaphies being performed each year,1 ' the corporate sector was not far behind in aggressively marketing laparoscopic hernia repair. The media's attention also stimulated many patients to seek this new technology for hernia repair.

[3] [4] [5] At the time of this development, most herniorrhaphies were already being performed under local anesthesia on an ambulatory basis.1 • Yet general surgeons with a specific interest in laparoscopy embraced laparoscopic hernia repair despite its incumbent general anesthesia, peritoneal invasion, and unknown results. Not all the surgeons supported this procedure.1 • 1 •

Now, only a short time after the introduction of laparoscopic hernia repair, several techniques for laparoscopic herniorrhaphy have evolved. The initial complications associated with the learning curve have clearly improved. But is this procedure a triumph of technology over prudence? How much can one improve on an open tension-free mesh hernia repair, performed under local anesthesia, without peritoneal invasion, on an outpatient basis? Any change from an already accepted, safe, time-tested procedure should be carefully weighed.

This chapter aims to review the history and development of laparoscopic hernia repair, examine anatomy pertaining to laparoscopic hernia repair, outline the various laparoscopic procedures, describe the technical details, review outcomes and results, and evaluate the place of laparoscopy in the current surgical armamentarium. HISTORY OF INGUINAL HERNIORRHAPHY

Controversy and hernia repair have been intertwined since the Middle Ages, when the point of debate was whether herniorrhaphy should be accompanied by orchiectomy. In 1884, Bassini developed his technique for inguinal herniopathy in which division of the cremaster muscle and posterior wall were key features. Several modifications of this original technique were described by Halsted, Ferguson,

McVay,[ ] Tanner,[ ] Shouldice,[ ] and others. Despite more than a century elapsing since Bassini's work, the recurrence rates have persisted at about 10% after open repair. The next advance in hernia repair was the application of synthetic mesh. This advance is credited to Horwich, [ ] who, in 1958, used elasticated nylon in patients with large or recurrent hernias. Usher and Wallace subsequently described the

clinical use of polypropylene mesh1 • and reported their work on tissue reaction to prosthetic mesh.1 • The initial common use of mesh was restricted to large direct, large sliding, and recurrent inguinal hernias. Some authors, such as PattJ • suggested using mesh for all types of hernia. Soon, a school of thought emerged suggesting that the cause of postoperative pain and failed hernia repair was the tissue tension

at the suture line. Lichtenstein popularized the idea of avoiding tension by the use of mesh for all types of hernias. He reported excellent results, with a recurrence rate of 0.25%.1 • 1 • 1 •

The preperitoneal approach to groin herniorrhaphy owes its origins to Cheatle. The use of large pieces of mesh in the preperitoneal space of Bogros has been reported to have low recurrence rates (1.4 to 2.2%) by several authorities. The current laparoscopic hernia repair technique can be thought of as a synthesis of these two procedures, that is, the tension-free mesh repair (Lichtenstein) and the preperitoneal repair.

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