Inguinal Hernia Operations

Mesh repairs are considered the standard by most in the surgical community. Several hernia specialists however believe that mesh is overutilized in most hernias. In most studies, the use of mesh did not result in a statistically significant increase in chronic pain or complications. The use of mesh however was correlated with a lower recurrence rate (about 1-5%). There are rare cases of well-documented mesh-related illness due to uncommon immune reactions.

Open repair with mesh (Lichtenstein)
Benefits of this repair include not requiring general anesthesia and intubation. Furthermore, direct defects can be plicated safely (i.e. closed) prior to mesh patch placement. Meshes used can be light-weight or medium-weight (there is generally no need for heavy-weight meshes with this approach). 

Laparoscopic repair with mesh (TEP)
Benefits of this repair include probably slightly less pain and routinely covering the femoral space. This approach does have a higher rate of complications such as hematomas. Furthermore, general endotracheal anesthesia is required, and the closure of direct defects is not performed due to inability to visualize the nerves from this approach. Meshes used are most commonly medium-weight with light-weigh options available. 

Robotic repair with mesh (rTAPP)
Benefits of this repair include probably slightly less pain and routinely covering the femoral space. This approach does have a higher rate of complications such as hematomas and bowel obstruction. Furthermore, general endotracheal anesthesia is required, and the closure of direct defects is not performed due to inability to visualize the nerves from this approach. Meshes used can range from light-weight to medium-weight to heavy-weight depending on the anatomy encountered.

Many studies demonstrate that non-mesh repairs are comparable to mesh repairs. Therefore several hernia specialists believe that non-mesh repairs are equivalent when performed by experts (recurrence rates of 3-6%). Most agree that these repairs should either not be used or used with caution in patients with risk factors for recurrence (e.g. recurrent hernias, obesity, and smoking). 

Shouldice
Benefits of this repair include a long track record from the Shouldice Clinic. This repair uses four layers to distribute the tension of a Bassini Repair resulting in superior outcomes. It does require opening the floor even in patients with intact floors. 

Desarda
Benefits of this repair include less tension as a strip of external oblique is used to keep the conjoint tendon and inguinal ligament in connection. This more closely mirrors the tension-free Lichtenstein mesh repair whilst using a strip of physiologically active tissue in place of a mesh.

These repairs are not as well studied but show promise in preliminary research. Selection of one of these procedures requires a pre-operative ultrasound and more in-depth analysis prior to operation to assess for suitability. We expect recurrence rates to be consistent with non-mesh repairs, e.g. 3-6%. 

Laparoscopic/robotic high ligation
For appropriately selected patients, this may be the least invasive procedure available in terms of pain and tissue dissection. This procedure, though requiring general endotracheal anesthesia, is the quickest procedure resulting in the least amount of time under anesthesia. This repair is adapted from pediatric hernia repairs for adults with similar hernia pathophysiology. Cord lipomas and direct hernias are unable to be addressed with this procedure. 

Laparoscopic absorbable mesh (aTEP)
This procedure is equivalent to the standard TEP but utilizes an absorbable mesh. This requires general endotracheal anesthesia. We do not offer this to patients with direct hernias as we do not offer posterior defect closure due to inability to visualize the nerves from this approach. 

Open high ligation
This is an open approach to high ligation. This procedure does not require general endotracheal anesthesia. This approach is possibly inferior to laparoscopic high ligation due to additional dissection needed. But it may be coupled with modified Marcy sutures to tighten the internal ring (likely similar or equivalent to the "Kang Repair") which in theory would have a potential advantage over the laparoscopic high ligation.