3 The technology
3.1 Laparoscopic surgery is a minimal-access technique that allows the hernia repair to be undertaken without the need to open the abdominal wall. Small incisions are made for the laparoscope and operating instruments, and synthetic mesh is usually used to close the hernia and prevent recurrence. There are two main approaches for the laparoscopic repair of inguinal hernias.
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Transabdominal preperitoneal (TAPP) repair involves access to the hernia through the peritoneal cavity. Mesh is inserted through the peritoneum and placed over all potential hernia sites in the inguinal region. The peritoneum is then closed above the mesh.
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Totally extraperitoneal (TEP) repair is the newer laparoscopic technique, in which the hernia site is accessed via the preperitoneal plane without entering the peritoneal cavity. TEP repair is considered to be technically more difficult than the TAPP technique, but it may reduce the risk of damage to intra-abdominal organs.
3.2 The surgical approach to inguinal hernia repair is the main focus of this appraisal; other issues, such as comparisons between TAPP and TEP and the use of laparoscopic surgery in special subgroups (for example, bilateral or recurrent hernia), are subsidiary considerations.
3.3 The potential benefits of using a laparoscopic approach include reduced postoperative pain, earlier return to normal activities and a reduction in long-term pain and numbness. The repair of bilateral hernias (including occult hernias detected during contralateral inspection at the time of a unilateral repair) may be undertaken during the same operation.
3.4 Laparoscopic surgery is associated with additional costs, for the endoscopy system (video unit, monitor, endoscope and CO2 insufflator) and instruments (staplers, diathermy scissors or ports), although these may be reusable. The cost of laparoscopic surgery is highly dependent on whether disposable or reusable equipment is used.