Technical considerations of the different approaches to laparoscopic herniorrhaphy: an analysis of 500 cases.

Between April 1991 and April 1994, 500 laparoscopic herniorrhaphies have been performed at our institution. The transabdominal preperitoneal approach was used for 290 repairs, and the total extraperitoneal approach was used for 210 repairs. Although both repairs resulted in acceptable recurrence and complication rates, we adopted the total extraperitoneal approach in June 1993, with a resulting lower recurrence rate (0.5% versus 2.1%) and lower complication rate (3.1% versus 11.1%) when compared with the transabdominal approach. In this retrospective review, four epigastric vessel injuries (1.6%) and one bowel obstruction from a port hernia (0.5%) were attributed to the lateral port placement in the transabdominal approach. There were also two visceral injuries (1.0%) from entering the abdominal cavity in the transabdominal approach. The one visceral injury (0.6%) in the total extraperitoneal approach was a result of the balloon dissection in a patient with multiple previous lower abdominal operations. Better exposure and lateral visualization of the extraperitoneal space has led to less incidence of nerve injury (0.0% versus 2.4%) and a lower recurrence rate (0.5% versus 2.1%) in the total extraperitoneal approach. The total extraperitoneal approach to laparoscopic herniorrhaphy compares favorably to the transabdominal approach in our institution. The improved results may have been due to the technical differences between these approaches.