By Victoria Stern

The idiom “great minds think alike” may sound like a cliché, but it rings true in the era of laparoscopic surgery. Innovative ideas and techniques from many laparoscopic pioneers emerged independently at similar periods.

Around the time that German gynecologist Kurt Semm, MD, was trying to popularize a range of laparoscopic procedures to treat gynecologic issues (General Surgery News April 2013, page 8), Ralph Ger, MD, FRCS, FACS, repaired an inguinal hernia through a laparoscope for the first time. But unlike laparoscopic appendectomy or cholecystectomy repairs, techniques to perfect laparoscopic hernia repair evolved over decades.

image
Intraoperative view of TEP repair.
1. Genital ramus of genitofemoral nerve.
2. Preperitoneal lipom and spermatic cord.

In the late 1970s, Dr. Ger, chairman of the Department of Surgery, Nassau Hospital in Mineola, N.Y., and professor of surgery, State University of New York at Stony Brook, treated a series of 13 patients with inguinal hernias, 12 of which were repaired through an open incision. For the 13th patient, however, Dr. Ger decided to try something different: He passed a laparoscope through a small subumbilical puncture and closed the neck of the sac with a series of staples, performing the first laparoscopic-guided inguinal hernia repair (Ann R Coll Surg Engl 1982;64:342-344). Motivated by this success, Dr. Ger experimented with laparoscopic inguinal hernia repair, successfully closing the neck of the hernia sac laparoscopically in 14 of 15 beagle dogs (Am J Surg 1990;159:370-373).

In 1989, gynecologist Sergei Bogojavlensky, MD, first used a laparoscopic plug-and-patch technique, stoppering the hole with a rolled-up piece of polypropylene mesh during inguinal and femoral hernia repairs. That same year, Leonard Schultz, MD, a surgeon at Abbott Northwestern Hospital, Minneapolis, refined the plug-and-patch method and reported the first series of laparoscopic herniorrhaphy, in which he passed pieces of polypropylene mesh through a laparoscope, stuffing some of them into the orifice of the hernia and placing several sheets over the defect (J Laparoendosc Surg 1990;1:41-45).

The plug-and-patch approach was already a popular procedure for open hernia repair, first introduced in 1968 by Irv Lichtenstein, MD, to fix femoral and small direct recurrent inguinal hernias, and later adapted by Arthur Gilbert, MD, in 1985, to repair indirect inguinal hernias.

Although the procedure initially showed promise for laparoscopic hernia repair, longer follow-up revealed a recurrence rate of 15% to 20%. Dr. Schultz found that the mesh often would migrate and patients would develop mesh hernias. As a result, this method, along with a variation introduced by J.D. Corbitt Jr., MD (Surg Laparosc Endosc 1991;1:23-25), was soon abandoned.

“Because most surgeons couldn’t suture and there were no tacking devices yet, surgeons were rolling polypropylene mesh up like a cigarette butt and shoving it down the hernia with the idea that it would scar in and resolve the defect,” said Robert Sewell, MD, a general surgeon at the Master Center for Minimally Invasive Surgery in Southlake, Texas. “It didn’t work and caused most surgeons to look at laparoscopic hernia repair as a gimmick. Even when better techniques started to evolve, we were always trying to overcome the negative first impression created by the plug repair.”

In 1990, Robert J. Fitzgibbons, MD, and Charles J. Filipi, MD, both currently professors of surgery at Creighton University School of Medicine, Omaha, were looking for ways to mimic the success of laparoscopic cholecystectomy in hernia repair and began experimenting with pigs in the lab. The duo came up with a new repair, the transabdominal preperitoneal (TAPP) approach.

“We figured out a way to cover all critical anatomical structures with mesh and tack it in place,” recalled Dr. Fitzgibbons.

At about the same time, Maurice Arregui, MD, FACS, also began experimenting with laparoscopic options for inguinal hernia repair.

“I recalled the Rives-Stoppa open repair and thought this might be the best approach, so I tried mimicking this technique using laparoscopic tools,” said Dr. Arregui, director of fellowship in Advanced GI Surgery, Laparoscopy, Endoscopy and Ultrasound at St. Vincent Hospital and Health Care Center, in Indianapolis.

In 1992, Dr. Arregui reported the results of a TAPP series in humans, performing 61 laparoscopic preperitoneal mesh repairs, using either Prolene (Ethicon) or Marlex (Davol/Bard) mesh, on 52 patients from October 1990 to December 1991 (Surg Laparosc Endosc 1992;2:53-58).

That same year, Yves-Marie Dion, MD, and Jacques Morin, MD, Department of Surgery, L’Hôpital Saint-François d’Assise, Quebec, Canada, independently published the results of 10 inguinal herniorrhaphies performed via TAPP using Prolene mesh (Can J Surg 1992;35:209-212). In both studies, the authors found that all patients recovered quickly compared with the open technique, and experienced less pain and no recurrences. Results of subsequent studies evaluating the efficacy of TAPP have shown recurrence rates of less than 1% (Surg Endosc 1995;9:16-21).

Although the TAPP technique worked very well, Drs. Fitzgibbons and Filipi wondered why they had to open the preperitoneal space and do an extensive dissection instead of simply placing the mesh one layer deeper, directly over the peritoneum. With this question in mind, they developed the intraperitoneal onlay patch (IPOM) technique, which averted the need for significant dissection by placing a piece of mesh over the peritoneal defect and securing it with staples.

Surgeons Frederick Toy, MD, and Roy T. Smoot Jr., MD, FACS, also were investigating the efficacy of IPOM, reporting positive short-term results in 10 patients who had polytetrafluoroethylene mesh secured to the inguinal floor using staples (Surg Laparosc Endosc 1991;1:151-155). In a later series of 75 patients, IPOM was associated with a low recurrence rate (2.4%), minimal postoperative pain and short recovery time after 20 months (J Laparoendosc Surg 1992;2:197-205).

Soon after, surgeons discovered that although IPOM worked well for repairing indirect and small hernias, it was not ideal for direct hernias or larger hernias. Additionally, intra-abdominal mesh could become involved when an unrelated intra-abdominal infection, such as appendicitis, occurred.

“As a result, many people thought this technique wouldn’t be a good long-term solution,” said Jeffrey Ponsky, MD, Oliver H. Payne Professor and chairman, Department of Surgery, Case Western Reserve University School of Medicine, and surgeon in chief, University Hospitals, Case Medical Center, Cleveland.

Although IPOM didn’t catch on for inguinal hernia repair, the technique is used currently to repair ventral hernias, Dr. Fitzgibbons noted.

TAPP Versus TEP: Laparoscopic Standard of Care

Despite the success of TAPP, many surgeons still thought that entering the abdominal cavity was too invasive for an inguinal hernia repair, and so a twist on TAPP emerged. In a totally extraperitoneal prosthetic (TEP) repair, surgeons do not enter the peritoneal cavity but instead dissect directly into the preperitoneal space with the laparoscope. The key is to create an extraperitoneal space between the peritoneum and the abdominal wall. Radical dissection of the preperitoneal space and mesh placement are then performed just as they are in TAPP.

It remains unclear exactly how the TEP approach came about, although it may have arisen from the animal training labs for laparoscopic cholecystectomy. Many surgeons who taught courses would tinker in the labs afterward, experimenting with new techniques, Dr. Fitzgibbons recalled. During one such session, general surgeon Barry McKernan, MD, managed to create a space in the preperitoneum without entering the abdomen completely, and TEP was born.

French laparoscopic surgeon Jean-Louis Dulucq, MD, also a pioneer of TEP, performed a large series of 864 inguinal hernia repairs from 1990 to 1995. This series, however, largely went unnoticed in the United States and was only described years later in the book Retroperitoneoscopy, published in 1996.

Dr. McKernan and surgeon George Ferzli, MD, FACS, helped popularize TEP. In one early report, Dr. McKernan showed success repairing 51 direct and indirect inguinal hernias using this approach, with no unusual complications and all patients returning home after one day and to work within a week of the procedure (Surg Endosc1993;7:26-28).

The Balloon

Initially, surgeons did the TEP repair without a balloon. “At this time, we did manual dissection to access the preperitoneal space, which many found to be tedious and difficult, but doable,” said Guy Voeller, MD, FACS, professor of surgery at University of Tennessee Health Science Center, in Memphis, adding that once balloon technology emerged, TEP became more feasible for more surgeons.

In 1989, Jay Watkins, a businessman and designer, approached Albert Chin, MD, who had developed a balloon angioplasty catheter with Tom Fogarty, MD, in the mid-1970s, and Fred Moll, MD, who had developed and patented the first safety shield trocar for laparoscopy, about cofounding a device company focusing on laparoscopic technologies. Together, the trio formed Origin Medsystems, and Drs. Chin and Moll began creating devices to simplify laparoscopic procedures, particularly structural balloons that could replace gas insufflation. By 1991, Dr. Chin had developed a prototype of a simple elastic balloon with an internal endoscope, which could create a large preperitoneal cavity. This Preperitoneal Dissection Balloon (PDB) allowed surgeons to view critical structures through the transparent wall of the balloon and insert a structural balloon within the space.

During that time, Maciej Kieturakis, MD, a surgeon in private practice in Redwood City, Calif., took a standard esophageal catheter, called a Sengstaken-Blakemore tube, to access the preperitoneal space. He used the tube, which has a balloon on one end, to inflate the preperitoneal space and performed the first TEP procedure with a balloon. Later, Dr. Kieturakis published a series of his TEP balloon approach (Am J Surg 1994;168:603-604).

Dr. Moll and Origin’s director of marketing, Milt McColl, MD, heard that Dr. Kieturakis had performed laparoscopic preperitoneal hernia repair with a balloon, and arranged a meeting.

“In this meeting, Dr. Kieturakis revealed that he had been inflating the small spherical distal balloon of a Sengstaken-Blakemore tube in the preperitoneal space to prepare a surgical cavity for inguinal hernia repair,” Dr. Chin recalled.

In a subsequent encounter, Drs. Moll and McColl told Dr. Kieturakis about their PDB balloon, and offered him a royalty to join forces with Origin. Dr. Kieturakis turned them down and teamed up with Dr. Fogarty to form a separate startup company called General Surgical Innovations (GSI), developing the blind balloon dissection. Both Origin Medsystems and GSI commercialized their devices.

The balloon helped catapult TEP as a standard for laparoscopic inguinal hernia repair. Dr. Voeller taught the procedure with the balloon to surgeons at his lab in Memphis and abroad.

“The balloons allowed for surgeons to access the preperitoneal space quickly, with minimal bleeding,” Dr. Voeller said. “Although it’s possible to do TEP without a balloon, the balloon allowed surgeons to do repair more easily, and today the majority of TEP repair are done with the balloons.”

Several other technologies, including in-line needle holders and disposable staplers, helped laparoscopic inguinal hernia repair begin to take hold in the surgical community.

“Ethicon Endo-Surgery and U.S. Surgical Corporation developed staplers, which revolutionized the way hernia repair could be performed,” Dr. Sewell said. “Surgeons didn’t have to suture; they could cover the defect with mesh without any tension.”

TAPP or TEP: Which Is Better?

Reports emerged assessing the TAPP and TEP techniques. Edward Felix, MD and his colleagues from Fresno, Calif., published a study comparing 733 TAPP and 382 TEP in 866 patients (Surg Endosc 1995;9:984-989). The authors reported 11 major complications in the TAPP group versus no complications and one recurrence in the TEP group.

That same year, several surgeons, including Drs. Arregui, Fitzgibbons and McKernan, collected results from a series of 3,229 laparoscopic hernia repairs in 2,559 patients using a range of techniques, including TAPP (60% of patients), TEP (18%), laparoscopic plug-and-patch (9%) and IPOM (11%) (Surg Endosc 1995;9:16-21). The TAPP and TEP had the lowest rates of recurrence (1% and 0%, respectively) and complications (7% and 10%, respectively).

In 1998, Drs. Felix, McKernan, Sewell and their colleagues conducted a retrospective review to confirm the effectiveness of TAPP and TEP, comparing results in 7,661 patients who underwent 10,053 hernia repairs (Surg Endosc 1998;12:226-231). Follow-up revealed that 35 TAPP and TEP repairs failed (0.4%), demonstrating an extremely low recurrence for the techniques.

“The results were exemplary,” Dr. Felix recalled. “Here, we showed that different surgeons using different laparoscopic techniques could get the same results. This was a milestone paper that put laparoscopic hernia repair on the map.”

Today, the majority of laparoscopic inguinal hernia repairs are performed using TAPP or TEP approaches with polypropylene prosthesis. The choice of procedure depends mostly on surgeon preference.

“TAPP is perhaps my favorite laparoscopic inguinal hernia repair because it is a safe and sturdy repair and easy to learn and teach,” Dr. Ponsky said. Drs. Sewell and Fitzgibbons also predominantly use the TAPP approach, noting that they “find it easier.”

After watching a video of surgeon Edward Phillips, MD, perform TEP, Dr. Arregui had a change of heart. “I thought TEP would be better than TAPP because it more closely mimicked the open approach and limited opportunities for complications,” recalled Dr. Arregui, who now exclusively does TEP.

Dr. Felix also prefers the TEP approach, performing 95% of his cases using TEP and only 5% with TAPP, as does Dr. Voeller, who has done 3,500 TEPs. Still, both agree the two approaches are essentially equivalent.

Laparoscopy Versus Open: Controversy

Although surgeons attempted to replicate the success of laparoscopic cholecystectomy with hernia surgery, the real benefits of laparoscopic hernia repair remained questionable. As a result, in May 1993, Dr. Arregui and his colleague Robert Nagan, MD, organized the “Hernias ’93, Advances or Controversies” conference, held in Indianapolis, inviting the premier hernia experts from around the world. The goal of the meeting was to promote the laparoscopic approach and discuss the effectiveness of different open and laparoscopic techniques.

Arthur Gilbert, MD, associate clinical professor of surgery at the University of Miami Medical School, now retired, and first president of the American Hernia Society, recalled the tension in the conference room, which was divided between the sharply dressed, young laparoscopic surgeons on one side and the older, dowdy crowd of open surgeons on the other. “You could see one side talking about the other like they were ready to go to war,” he said. “It was the most contentious meeting I’ve been to in my 50-year surgical career.”

Drs. Gilbert and Voeller agreed that laparoscopic inguinal hernia repair hadn’t yet matured by 1993, which resulted in unnecessary complications, including bowel and blood vessel injuries, that didn’t occur in the open repair.

“The complications seen in the laparoscopic approach were awful, so when the older guard made their presentation, they stressed complications seen with laparoscopy,” Dr. Gilbert said. “And when laparoscopic surgeons made their presentations, they stressed the complications seen with open surgery. It became a mud-slinging contest at that point.”

Dr. Voeller believes that part of the reason open hernia repair experts were so opposed to laparoscopic repair was that they felt threatened. Dr. Gilbert agreed, recalling in 1990 being approached by industry representatives who informed him that if he did not switch to laparoscopic hernia surgery, he would lose patients and go out of business.

Although there was a lot of bickering during the meeting, tempers calmed afterward. “What came out of that meeting was a sense of civility,” Dr. Gilbert said. “I felt that we recognized that laparoscopic hernia surgery was here to stay, and those who thought it was a better technique would devote themselves to it, but those who wanted to stick with open surgery would do so.”

Dr. Arregui agreed, noting that “although initially polarizing the open versus laparoscopic camps, [the meeting] ultimately created relationships that grew into friendships and combined efforts to improve the art and science of hernia repair.”

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Several years later, Dr. Sewell moderated a half-day session on inguinal hernia repair at an American Society of General Surgeons meeting in Toronto. Experts from all over the country presented their experiences with their preferred techniques, including open approaches, such as Lichtenstein and Kugel repair as well as laparoscopic techniques, such as TAPP and TEP.

“I titled that session ‘Hernia Wars,’ because there was so much controversy about what the best hernia repair was,” Dr. Sewell said.

In Dr. Sewell’s opening remarks, he illustrated two types of surgeries with an image of a bulldozer and another of an architect sitting at a drawing board. “There are bulldozer operations like gallbladder and appendectomy where surgeons are trying to remove something,” he said. “And there are reconstructive procedures, like hernia repair, where surgeons are trying to rebuild something.”

The next slide read simply, ‘The hernia surgeon’ with a picture of the Peanuts cartoon character Linus, holding his security blanket and sucking his thumb. Dr. Sewell’s message was that hernia surgeons tend to hold on to the procedure they are most comfortable with, like they would a security blanket.

The panel of experts presented their results and proceeded to debate which procedure had the fewest complications, recurrences and pain. In the final analysis, Dr. Sewell asked the panel, ‘If you were to have a hernia repair yourself and needed it fixed by some technique other than your own, what technique would you choose?’

“Every member, except the expert from the Lichtenstein Clinic, who simply refused to answer the question, said they would have their hernia repaired laparoscopically,” Dr. Sewell recalled. “Every surgeon recognized the value of the tension-free laparoscopic approach.”

Dr. Voeller, recalling the spirit of the open-versus-laparoscopy debates, fondly recounted his arguments with surgeon George Wantz, MD, a staunch advocate of open preperitoneal repair. During one debate, after TEP had become more mainstream, Dr. Wantz approached Dr. Voeller and said, “‘Guy, don’t tell anyone, but if I had a hernia, I would want you to do it laparoscopically.’ This was the day I knew the TEP was here to stay.”

Over the years, studies have reported a range of recurrence rates for open techniques. One study of patients undergoing a tension-free open Lichtenstein repair with polypropylene mesh reported a 0.1% recurrence rate (Eur J Surg 1996;162:447-453), while another found a recurrence rate ranging from 5% after tension-free open Lichtenstein repair to 15% after either Cooper’s ligament or abdominal ring repair (Am J Surg 1996;172:315-319). Studies comparing pain after open and TEP repairs found significantly more pain and disability in patients who had open mesh repair than with TEP (Br J Surg 2002;89:1476-1479; Ann Surg 1996;224:598-602). And a randomized controlled study comparing laparoscopic and open tension-free repairs reported that the laparoscopic approach comes with lower recurrence rates (3% vs. 6%), less postoperative pain and earlier recovery (N Engl J Med 1997;336:1541-1547).

In contrast, a prospective, randomized controlled study, which compared laparoscopic and open tension-free repairs of inguinal hernias in 2,164 patients at 14 Veterans Affairs medical centers, showed a higher recurrence and complication rate in the laparoscopic group (10.1% and 39%, respectively) versus the open group (4.9% and 33.4%, respectively) (N Engl J Med 2004; 350:1819-1827).

The study received criticism from laparoscopists who felt that the surgeons involved in the trial were inexperienced, Dr. Voeller said. “Most of the TEP procedures were done by VA residents who were not yet experts in the TAPP or TEP repairs,” he said, adding that when the study compared recurrence rates for the open and laparoscopic procedures performed by highly experienced surgeons, there was no significant difference (5.1% for laparoscopic vs. 4.1% for open approach).

Because recurrence rates are similar for open and laparoscopic approaches when performed by experienced hands, Dr. Ponsky prefers laparoscopy if patients are healthy enough. “I do laparoscopic hernia repair in 60% of patients and open in about 40%, but which approach I choose depends heavily on the patient’s cardiac status, previous abdominal problems and surgeries, and the patient’s desire to get back to work. I tend to select the procedure based on the patient’s needs and desires as well as my preference.”

Hernia Repair Today

Now, of the 900,000 inguinal hernia repairs performed each year in the United States, about 20% to 30% are done laparoscopically, and according to data from the National Surgical Quality Improvement Project, 30% of recurrent inguinal hernias are repaired laparoscopically.

“However, these percentages vary widely from city to city and hospital to hospital, depending on the local expertise,” Dr. Felix said.

Reflecting on the laparoscopic hernia repair evolution, Dr. Felix said, “Laparoscopic hernia repair has had its ups and downs over the last 20 years. The laparoscopic hernia techniques are much harder to learn, so it never took off in the same way that laparoscopic cholecystectomy did, not because it’s inferior but because it’s not better in everyone’s hands.”

Despite the slower pace of acceptance, the intense debates and constant evolution of ideas and techniques made for an exciting experience.

“During the early 1990s, I was in the middle of the firestorm during the emergence of laparoscopy,” Dr. Ponsky said. “It was like being on cocaine. Every day was a high. Every week, we had discussions about new instruments, new techniques, new ideas—it was electric. It was the best time I’ve ever experienced in surgery.”

AT A GLANCE

In the late 1970s, surgeon Ralph Ger, MD, repaired an inguinal hernia through a laparoscope for the first time.

In 1989, gynecologist Sergei Bogojavlensky, MD, first used a laparoscopic plug-and-patch technique, stoppering the hole with a rolled-up piece of polypropylene mesh.

In 1990, Robert J. Fitzgibbons, MD, and Charles J. Filipi, MD, developed the transabdominal preperitoneal (TAPP) approach for hernia repair.

In the early 1990s, Maciej Kieturakis, MD, took a standard esophageal catheter, called a Sengstaken-Blakemore tube, to access the preperitoneal space. He used the tube, which has a balloon on one end, to inflate the preperitoneal space and performed the first TEP procedure with a balloon.