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Inguinal Hernias:

Inguinal Hernias:

Open vs. Laparoscopic vs. Robotic Surgery?

Advantages, disadvantages, and a common sense solution to this question

I met a gentleman the other day who was referred to a local surgeon for an inguinal hernia. He presented with a bulge in the groin that was causing him minimal symptoms and a fair amount of concern. When he got home from the procedure, he was surprised by the size of the incision and the painful recovery that followed. The surgeon had performed an open inguinal hernia repair. He then began to do some research and wondered why he wasn’t offered something less invasive.  

I have had similar discussions with patients who were offered robotic hernia surgery and were equally unhappy with their outcomes and recovery times. So, what are the surgical options available to patients? Why choose one over another? It really comes down to two key components of all operations – adequate visualization of the anatomy allowing proper diagnosis and treatment and surgeon experience. Patients often don’t have a choice because of limitations with their condition or a surgeon uncomfortable with different approaches.

So, what is an inguinal hernia? An inguinal hernia is a hole in the abdominal wall located in the groin. They can occur on both sides (bilateral). The three most common defects are direct and indirect inguinal and femoral types. In my opinion, it requires mesh placement for repair. Mesh complications are extremely low (less than 1 in 500) despite all the advertisements from lawyers. You may find surgeons willing to repair an inguinal hernia without mesh, however the recurrence rate approaches 25%.

There are benefits and potential problems with all three approaches so let’s dissect them down into easy explanations. Open surgery refers to making an incision directly over the surgical site, going through each layer of muscle or fascia to reach the problem area. It essentially means a large enough incision to correctly visualize the target, diagnose the abnormality, and surgically correct or remove it. It can mean a longer procedure time and longer recovery time compared to minimally invasive approaches. Most surgeons over the age of 50 have done numerous open cases compared to their younger colleagues. It is an important tool to master but in my opinion, should not be your only option.

So when do I recommend an open approach? For inguinal (groin) hernias, I offer this to patients who have had previous failed minimally invasive hernia repair (laparoscopic or robotic). The latter two approaches repair the hernia from the inside compared to the outside of the pelvis. The body heals by forming some scar tissue and approaching a recurrent hernia from the outside (open repair) avoids the scar tissue from the previous operation. Also, for the same reason, if a patient has had numerous abdominal operations, an open repair may be indicated.  

My open repair usually requires 20 minutes of operative time and the recovery time is very close to my laparoscopic cases. My incision is around 2 inches and heals well. The mesh I use is Progrip by Medtronic which is sutured in place. Open repair was the first type of hernia repair I learned long ago, and, though it is not my first choice for most patients, I have plenty of experience. It works well under certain circumstances.  

Robotic inguinal hernia repair is a type of laparoscopic repair in which the surgeon makes the initial incisions, places the instruments, then walks across the room to sit at a console which looks like the most expensive video game you have seen (because it is). The repair is performed within the pelvic space exposing the defect in the abdominal wall and placing mesh. The mesh is sutured or tacked in place. 

I have performed numerous robotic operations but ultimately abandoned the approach for the following reasons:

  1. Even in well trained hands, the procedure takes three times longer than my laparoscopic repairs. This means longer anesthesia and more time for things to go wrong.
  2. The incisions are actually larger than for traditional laparoscopic repairs (8 mm vs 5 mm).
  3. Higher complication rates.
  4. Much steeper learning curve for the surgeon. Surgeons in their early experience usually take hours for an operation.
  5. Most commonly performed in the hospital as an outpatient which could increase your cost, has a higher infection rate, and is less efficient than a quality ambulatory surgery center.

Robotic operations are very beneficial for the fields of cardiothoracic, urologic, gynecological oncology, and certain procedures of colorectal surgery requiring resection deep within the pelvis. However, for general surgery, the technology needs  more improvement in efficiency and economy.

Finally, let’s discuss laparoscopic inguinal hernia repair, my preferred approach. The patient undergoes general anesthesia. I make three small incisions and place a 12 mm trocar (a sleeve which allows removal of instruments without losing pneumoperitoneum) and two 5 mm trocars. Under magnified visualization of the camera, I dissect out the tissue herniated through the defect and place a 10 x 15 cm piece of Medtronic Progrip mesh. The mesh covers the defect of concern but also covers other potential defects which could later develop into a hernia. I remove the trocars and close the incisions. The procedure takes me around 15 minutes on average.  

I have performed thousands of these and it is my preferred approach because of several factors:

  1. It is quick and efficient. Less anesthesia time means quicker recovery because less amounts of anesthesia medications are given for the body to metabolize.
  2. Usually significantly less postoperative pain. My patients typically take prescribed narcotics for an average of two days.
  3. Patients (who do not perform heavy lifting) may return to work the next day. Most take off a few days only.
  4. My recurrence rate and complication rate are around 1 in 300.
  5. I never leave the patient’s side until my assistant starts closing the three small incisions.

In summary, inguinal hernias encompass several defects in the groin that may or may not be symptomatic. Regardless, all should be repaired because they grow with time and become more complicated to repair. They do not heal without an operation. Three approaches have their advantages and disadvantages and require mesh placement for the best results. Feel free to book a consultation with me to discuss your options. 

Mark S. Talbert, MD

Talbert General Surgery, LLC

129 W. Hibiscus Blvd, Ste D

Melbourne, FL  32903

321-372-1372