Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review E. Kuhry, 1,3 R. N. van Veen, 1 H. R. Langeveld, 1 E. W. Steyerberg, 2 J. Jeekel, 1 H. J. Bonjer 4 1 Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands 2 Department of Public Health, Erasmus University, Rotterdam, The Netherlands 3 Department of Surgery, Namsos Sykehuset, 7800 Namsos, Norway 4 Department of Surgery, Dalhousie University, Halifax, Canada Received: 1 March 2006/Accepted: 27 May 2006/Online publication: 14 December 2006 Abstract Background: Although a large number of surgeons currently perform endoscopic hernia surgery using a total extraperitoneal (TEP) approach, reviews pub- lished to date are based mainly on trials that compare laparoscopic transabdominal preperitoneal (TAPP) repair with various types of open inguinal hernia re- pair. Methods: A qualitative analysis of randomized trials comparing TEP with open mesh or sutured repair. Results: In this review, 4,231 patients were included in 23 trials. In 10 of 15 trials, TEP repair was associated with longer surgery time than open repair. A shorter postoperative hospital stay after TEP repair than after open repair was reported in 6 of 11 trials. In 8 of 9 trials, the time until return to work was significantly shorter after TEP repair. Hospital costs were signifi- cantly higher for TEP than for open repair in all four trials that included an economic evaluation. Most trials (n = 14) reported no differences in subsequent recurrence rates between TEP and open repair. Conclusions: The findings showed that endoscopic TEP repair is associated with longer surgery time, shorter postoperative hospital stay, earlier return to work, and recurrence rates similar to those for open inguinal hernia repair. The procedure involves greater expenses for hospitals, but appears to be cost effective from a societal perspective. The TEP technique is a serious option for mesh repair of primary hernias. Key words: Endoscopic total extraperitoneal hernia repair — TEP Inguinal hernia repair is one of the most common surgical procedures. In the United States alone, more than 700,000 of these procedures are performed each year, incurring approximately 3.5 billion dollars of hospital costs [1]. Optimizing surgical technique to im- prove short-term outcome and reduce the rate of recurrence is therefore of great value to health care. Over the past 20 years, several hernia repair tech- niques have been introduced [2–4]. Reducing the rate of recurrence has been the main incentive for the devel- opment of these new techniques. The introduction of the Lichtenstein tension-free hernioplasty, which uses a mesh to reinforce the abdominal wall, has decreased recurrence rates greatly [5]. Another advantage of the Lichtenstein hernia repair is that it is a relatively straightforward and easy-to-learn procedure requiring minimal dissection that can be performed using local anesthesia. In addition, because the technique is tension free, it is associated with significantly less postoperative pain and discomfort than conventional open repair [6]. Since the introduction of laparoscopic inguinal her- nia repair, most of the ongoing discussion has focused on the choice between open or endoscopic surgery. Endo- scopic inguinal hernia repair is associated with shorter recovery periods, earlier return to daily activities and work, and fewer postoperative complications [7]. Some authors suggest that endoscopic repair of recurrent her- nia is easier because it is performed in virgin tissue. On the other hand, endoscopic hernia repair requires special skills to overcome limitations inherent to this type of surgery such as loss of depth perception, limited range of motion, and reduced tactile feedback. As a conse- quence, endoscopic hernia repair has a significant learn- ing curve [8] and is associated with longer operating times [9]. Furthermore, some serious complications during laparoscopic transabdominal preperitoneal (TAPP) mesh repair have been reported [10–13], some even resulting in the death of a patient [11, 13]. Some authors propose that Correspondence to: E. Kuhry Surg Endosc (2007) 21: 161–166 DOI: 10.1007/s00464-006-0167-4 Ó Springer Science+Business Media, Inc. 2006