COLLECTIVE REVIEWS Is Laparoscopic Inguinal Hernia Repair an Operation of the Past? Lorelei J Grunwaldt, MD, Steven D Schwaitzberg, MD, FACS, David W Rattner, MD, FACS, Daniel B Jones, MD, FACS There is an ongoing debate about whether to repair pri- mary, unilateral inguinal hernias by the laparoscopic or the open method. Many agree that laparoscopic repair is better for bilateral or recurrent hernias, but its use for primary, unilateral hernias is controversial. Sixteen ran- domized, controlled trials and metaanalyses that compared these two techniques demonstrated that laparoscopic repair has a definite role in modern surgery (Table 1). The VA Cooperative Study is the most recently published large, prospective, randomized, controlled trial that compared laparascopic to open repair. The authors concluded that open inguinal hernia repair is superior to laparoscopic inguinal hernia repair. They based their conclusion on a higher overall recurrence rate in the laparoscopic group (10% versus 4.9%) and a higher complication rate in the laparoscopic group (39% versus 33%). 1 This article might make one believe that laparoscopic inguinal her- nia repair is a procedure of the past. A thorough analysis of this admirable and ambitious project reveals many flaws; it simply cannot be accepted as the definitive work in this field. In this article we will discuss the drawbacks of the VA Study, and we will also delineate the shortcom- ings of some of the other published reviews in an at- tempt to illustrate why laparoscopic inguinal hernia re- pair is not a procedure of the past. Hernia revisited Hernia comes from the Greek word hernios, which means offshoot or bud. In his book entitled Hernia, Nyhus 2 stated, “The history of hernia repair is the his- tory of surgery.” It might seem that advancements in hernia surgery have surpassed the work of early surgeons. Lau, 3 in his history of inguinal hernia repair, pointed out that early laparoscopic surgery failed because the tenets of open surgery were not followed. When the basic prin- ciples of hernia surgery were revisited, laparoscopic methods began to succeed. To ensure low complication and recurrence rates, it is essential to have a complete understanding of the anatomy of the inguinal region. In his 1804 monograph, Cooper stated, “No disease of the human body, belonging to the province of the surgeon, requires in its treatment a greater combination of accu- rate anatomic knowledge, with surgical skill, than hernia in all its varieties.” 4 The VATrial failed to monitor or standardize the techniques used for repair. The VA Study versus hernia repair in the 21 st century After appendectomy, hernia repair is the most frequently performed general surgery operation. In the United States, there are more than 700,000 repairs performed each year. 5 McKinsey and Co estimated that laparo- scopic inguinal herniorraphy would become the proce- dure of choice a few years after it was introduced. They predicted that from 1993 to 1995, 50% of all repairs would be done laparoscopically.Today, the number of inguinal hernias repaired by the minimally invasive tech- nique is well below 50%. Why? The recommendation of the National Institute of Clinical Excellence (NICE) states that open mesh repair should be the procedure of choice for primary inguinal hernia and that the laparo- scopic approach should be limited to bilateral or recur- rent hernia. 6 Laparoscopic inguinal hernia repair is a safe and rea- sonable procedure. The complication rate is very low, comparing favorably with open repair (Table 2). The VA Cooperative Study concluded that the rate of complica- tions was higher in the laparoscopic group (39%) than in the open group (33%). It did not break down the com- plications according to whether a transabdominal pre- peritoneal (TAPP) or total extraperitoneal (TEP) repair was done. One large metaanalysis found that TAPP re- pair has a higher rate of serious complications thanTEP, with vascular and visceral injuries more frequent in the Received August 20, 2004; Revised October 21, 2004; Accepted October 22, 2004. From the Departments of Surgery, Beth Israel Deaconess Medical Center (Grunwaldt, Jones), Tufts-New England Medical Center (Schwaitzberg), and Massachusetts General Hospital (Rattner), Boston, MA. Correspondence address: Daniel B Jones, MD, FACS, Department of Sur- gery, Beth Israel Deaconess Medical Center, Shapiro TCC 355, Boston, MA 02215. 616 © 2005 by the American College of Surgeons ISSN 1072-7515/05/$30.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2004.10.033