Kaela Blake
Nora Fullington
Michael Reinhorn- 1University of Tennessee Graduate School of Medicine, Knoxville, TN, United States
- 2Boston Hernia, Wellesley, MA, United States
- 3Mass General Brigham-Newton Wellesley Hospital, Newton, MA, United States
- 4School of Medicine, Tufts University, Boston, MA, United States
In this edition of JAWS, many researchers have described numerous benefits of open preperitoneal (OPP) inguinal hernia repair. Overwhelming data suggests OPP inguinal hernia repair is a structurally sound, cost-effective approach for inguinal hernia repair with negligible rates of chronic groin pain and hernia recurrence [1–17]. The 2023 HerniaSurge Guidelines state that “open preperitoneal mesh techniques can achieve favorable results in terms of operating time, acute and chronic postoperative pain and return to work compared to Lichtenstein repair [17].” This is based on several recent randomized controlled trials that favor OPP to Lichtenstein for decreased pain and quicker recovery [18–21]. The guidelines also found that OPP and laparo-endoscopic approaches have comparable outcomes in terms of postoperative pain, recurrences and recovery, citing three randomized controlled trials [22–24]. Thus, OPP has outcomes that more similarly resemble those of Minimally Invasive Surgery (MIS) inguinal hernia repair [14, 17, 22–24] as opposed to Lichtenstein repairs.
Although OPP outcomes are more similar to those of MIS approaches, OPP is often categorized with Lichtenstein and tissue-based repairs in the broad category of “open” inguinal hernia repair [15]. We believe that categorizing these vastly different approaches together makes data collection and interpretation very difficult, leaving the surgical community unable to make clinically meaningful changes to improve patient outcomes. Furthermore, there are advantages of OPP compared to MIS approaches, such as decreasing cost, avoiding MIS equipment, and providing the opportunity to avoid general anesthesia [10, 14, 25–37]. We consider open preperitoneal repairs less invasive than the standard MIS operations as they do not enter the peritoneal cavity and are performed through one 3–4 cm incision instead of multiple incisions. The current standard, particularly in the United States, requires MIS equipment and general anesthesia to perform a preperitoneal inguinal hernia repair. In our view, this has created a platform for surgeons and device companies to market expensive technologies that may offer little to no benefit to individual patients while detrimentally increasing the cost of healthcare within our society. OPP provides a solution to this dilemma but needs more widespread acceptance, training opportunities and dedicated research with appropriate classification efforts to increase evidence-based recommendations.
The first step to distinguishing the benefits of OPP compared to other inguinal hernia repair techniques requires that the surgical community change the nomenclature regarding “open” inguinal hernia repairs. We have already done this for laparoscopic and robotic hernia surgery. We identify procedures by the anatomical planes, technology used, and location of mesh placement. We use terms like TAPP, TEP, and rTAPP to describe repairs that use laparoscopic or robotic technology to either enter the peritoneal cavity or stay in the pre-peritoneal plane. All of these procedures place mesh in the preperitoneal space and are commonly grouped together as “MIS” approaches in studies and publications. Similarly, several inguinal hernia repair techniques exist using an “open” approach. However, as previously mentioned, these approaches are significantly different from one another – both in planes dissected and placement of mesh - and have expectedly different outcomes. These open techniques must be clearly delineated in the literature and accepted in our surgical community in order to unify research efforts and guidelines. Therefore, we propose the following categorization of open inguinal hernia repair approaches:
• “Open tissue (OT)” repairs: This dissection occurs in the space below the external oblique aponeurosis and superficial to the pre-peritoneal space. These repairs include Bassini, Shouldice, Desarda and others.
• “Open Anterior Mesh (OAM)” repairs: This uniquely describes an anterior onlay mesh above the internal oblique musculature and deep to the external oblique aponeurosis, classically known as the Lichtenstein repair.
• “Open preperitoneal (OPP)” repairs: Describes open approaches where mesh is placed behind the abdominal wall, in the pre-peritoneal space. Examples include: TIPP, MOPP, TREPP, Kugel and various permutations of these repairs.
• “Open Anterior and Posterior Mesh (OAPM)” repairs: Although discouraged in international guidelines, many surgeons still utilize a hybrid technique where mesh is placed in both the anterior and posterior planes, such as Prolene Hernia System and Plug and Patch.
It is crucial that we correct the generalization that all “open” inguinal hernia repairs are equal. We must also overcome the marketing barrier that preperitoneal repairs require a laparoscope or robot. Only then can we objectively review the outcomes associated with various repairs, and identify specific operations that offer the best value to our patients, institutions and society as a whole.
Author Contributions
MR, KB, and NF all heavily edited the document. All authors contributed to the article and approved the submitted version.
Funding
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI Statement
The author(s) declare that no Generative AI was used in the creation of this manuscript.
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References
1. Lange, JF, Lange, MM, Voropai, DA, van Tilburg, MW, Pierie, JP, Ploeg, RJ, et al. Trans Rectus Sheath Extra-peritoneal Procedure (TREPP) for Inguinal Hernia: The First 1000 Patients. World J Surg (2014) 38(8):1922–8. doi:10.1007/s00268-014-2475-5
2. Ceriani, V, Faleschini, E, Bignami, P, Lodi, T, Roncaglia, O, Osio, C, et al. Kugel Hernia Repair: Open “Mini-Invasive” Technique. Personal Experience on 620 Patients. Hernia (2005) 9(4):344–7. doi:10.1007/s10029-005-0015-9
3. Bökkerink, WJ, Persoon, AM, Akkersdijk, WL, van Laarhoven, CJ, and Koning, GG. The TREPP as Alternative Technique for Recurrent Inguinal Hernia After Lichtenstein’s Repair: A Consecutive Case Series. Int J Surg (2017) 40:73–7. doi:10.1016/j.ijsu.2017.02.022
4. Persoon, AM, Bökkerink, WJV, Akkersdijk, WL, van Laarhoven, CJHM, and Koning, GG. Case Series of Recurrent Inguinal Hernia After Primary TREPP Repair: Re-TREPP Seems Feasible and Safe. Int J Surg Case Rep (2018) 51:292–5. doi:10.1016/j.ijscr.2018.08.060
5. Faessen, JL, Stoot, JHMB, and van Vugt, R. Safety and Efficacy in Inguinal Hernia Repair: A Retrospective Study Comparing TREPP, TEP and Lichtenstein (SETTLE). Hernia (2021) 25:1309–15. doi:10.1007/s10029-020-02361-w
6. Koning, GG, Andeweg, CS, Keus, F, van Tilburg, MW, van Laarhoven, CJ, and Akkersdijk, WL. The Transrectus Sheath Preperitoneal Mesh Repair for Inguinal Hernia: Technique, Rationale, and Results of the First 50 Cases. Hernia (2012) 16(3):295–9. doi:10.1007/s10029-011-0893-y
7. KugelRD., Minimally Invasive, Non Laparoscopic, Preperitoneal, and Sutureless, Inguinal Herniorrhaphy. Am J Surg (1999) 178(4):298–302. doi:10.1016/S0002-9610(9900181-6
8. Voyles, CR, Hamilton, BJ, Johnson, WD, and Kano, N. Meta-Analysis of Laparoscopic Inguinal Hernia Trials Favors Open Hernia Repair With Preperitoneal Mesh Prosthesis. Am J Surg (2002) 184:6–10. doi:10.1016/s0002-9610(02)00878-4
9. Aitola, P, Airo, I, and Matikainen, M. Laparoscopic Versus Open Preperitoneal Inguinal Hernia Repair: A Prospective Randomised Trial. Ann Chir Gynaecol (1998) 87:22–5.
10. Johansson, B, Hallerbäck, B, Glise, H, Anesten, B, Smedberg, S, and Román, J. Laparoscopic Mesh Versus Open Preperitoneal Mesh Versus Conventional Technique for Inguinal Hernia Repair: A Randomized Multicenter Trial (SCUR Hernia Repair Study). Ann Surg (1999) 230(2):225–31. doi:10.1097/00000658-199908000-00013
11. Hamza, Y, Gabr, E, Hammadi, H, and Khalil, R. Four-Arm Randomized Trial Comparing Laparoscopic and Open Hernia Repairs. Int J Surg (2010) 8(1):25–8. doi:10.1016/j.ijsu.2009.09.010
12. Zwols, TLR, Slagter, N, Veeger, NJGM, Möllers, MJW, Hess, DA, Jutte, E, et al. Transrectus Sheath Pre-Peritoneal (TREPP) Procedure Versus Totally Extraperitoneal (TEP) Procedure and Lichtenstein Technique: A Propensity-Score-Matched Analysis in Dutch High-Volume Regional Hospitals. Hernia (2020) 25:1265–70. doi:10.1007/s10029-020-02291-7
13. Hajibandeh, S, Hajibandeh, S, Evans, LA, Havard, T, Naguib, NN, and Helmy, AH. Meta-Analysis of the Outcomes of Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) for Inguinal Hernia. Author’s Reply. Hernia (2022) 26:1197–8. doi:10.1007/s10029-022-02636-4
14. Reinhorn, M, Fullington, N, Agarwal, D, Olson, MA, Ott, L, Canavan, A, et al. Posterior Mesh Inguinal Hernia Repairs: A Propensity Score Matched Analysis of Laparoscopic and Robotic Versus Open Approaches. Hernia (2023) 27(1):93–104. doi:10.1007/s10029-022-02680-0
15. Agarwal, D, Bharani, T, Fullington, N, Ott, L, Olson, M, Poulose, B, et al. Improved Patient-Reported Outcomes After Open Preperitoneal Inguinal Hernia Repair Compared to Anterior Lichtenstein Repair: 10-Year ACHQC Analysis. Hernia (2023) 27(5):1139–54. doi:10.1007/s10029-023-02852-6
16. Bharani, T, Agarwal, D, Fullington, N, Ott, L, Olson, M, McClain, D, et al. Open Preperitoneal Inguinal Hernia Repair Has Superior 1-Year Patient-Reported Outcomes Compared to Shouldice Non-Mesh Repair. Hernia (2024) 28(2):475–84. doi:10.1007/s10029-023-02936-3
17. Stabilini, C, van Veenendaal, N, Aasvang, E, Agresta, F, Aufenacker, T, Berrevoet, F, et al. Update of the International HerniaSurge Guidelines for Groin Hernia Management. BJS Open. 2023;7(5):zrad080. doi:10.1093/bjsopen/zrad080
18. Arslan, K, Erenoglu, B, Turan, E, Koksal, H, and Dogru, O. Minimally Invasive Preperitoneal Single-Layer Mesh Repair Versus Standard Lichtenstein Hernia Repair for Inguinal Hernia: A Prospective Randomized Trial. Hernia (2015) 19(3):373–81. doi:10.1007/s10029-014-1306-9
19. Suwa, K, Onda, S, Yasuda, J, Nakajima, S, Okamoto, T, and Yanaga, K. Single-Blind Randomized Clinical Trial of Transinguinal Preperitoneal Repair Using Self-Expanding Mesh Patch vs. Lichtenstein Repair for Adult Male Patients With Primary Unilateral Inguinal Hernia. Hernia (2021) 25(1):173–81. doi:10.1007/s10029-020-02301-8
20. Oprea, V, Grad, O, Gheorghescu, D, and Moga, D. Transinguinal Preperitoneal Mesh Plasty - An Alternative or a Dispensable Technique? A Prospective Analyze vs Lichtenstein Repair for Complex Unilateral Groin Hernias. Chirurgia (Bucur) (2019) 114(1):48–56. doi:10.21614/chirurgia.114.1.48
21. Djokovic, A, and Delibegovic, S. Tipp Versus the Lichtenstein and Shouldice Techniques in the Repair of Inguinal Hernias - Short-Term Results. Acta Chir Belg (2021) 121(4):235–41. doi:10.1080/00015458.2019.1706323
22. Akgul, N, Yaprak, M, Dogru, V, Balci, N, Arici, C, and Mesci, A. Quantitative Assessment of the Impacts of Stoppa Repair and Total Extraperitoneal Repair on the Lower Extremity Muscular Functions in Cases of Unilateral Inguinal Hernia: A Randomized Controlled Study. Hernia (2017) 21:377–82. doi:10.1007/s10029-016-1559-6
23. Kushwaha, JK, Enny, LE, Anand, A, Sonkar, AA, Kumar, A, and Pahwa, HS. A Prospective Randomized Controlled Trial Comparing Quality of Life Following Endoscopic Totally Extraperitoneal (TEP) Versus Open Stoppa Inguinal Hernioplasty. Surg Laparosc Endosc Percutan Tech (2017) 27:257–61. doi:10.1097/SLE.0000000000000450
24. Aksoy, N, Arslan, K, Dogru, O, Karahan, O, and Eryilmaz, MA. Comparison of Minimally Invasive Preperitoneal (MIP) Single-Layer Mesh Repair and Total Extraperitoneal (TEP) Repair for Inguinal Hernia in Terms of Postoperative Chronic Pain: A Prospective Randomized Trial. Turk J Surg (2019) 35:35–43. doi:10.5578/turkjsurg.4128
25. Nordin, P, Zetterström, H, Carlsson, P, and Nilsson, E. Cost-Effectiveness Analysis of Local, Regional and General Anaesthesia for Inguinal Hernia Repair Using Data From a Randomized Clinical Trial. Br J Surg (2007) 94(4):500–5. doi:10.1002/bjs.5543
26. Eklund, A, Carlsson, P, Rosenblad, A, Montgomery, A, Bergkvist, L, Rudberg, C, et al. Long-Term Cost-Minimization Analysis Comparing Laparoscopic With Open (Lichtenstein) Inguinal Hernia Repair. Br J Surg (2010) 97(5):765–71. doi:10.1002/bjs.6945
27. Khajanchee, YS, Kenyon, TAG, Hansen, PD, and Swanström, LL. Economic Evaluation of Laparoscopic and Open Inguinal Herniorrhaphies: The Effect of Cost-Containment Measures and Internal Hospital Policy Decisions on Costs and Charges. Hernia (2004) 8(3):196–202. doi:10.1007/s10029-004-0212-y
28. Liem, MS, Halsema, JA, van der Graaf, Y, Schrijvers, AJ, and van Vroonhoven, TJ. Cost-Effectiveness of Extraperitoneal Laparoscopic Inguinal Hernia Repair: A Randomized Comparison with Conventional Herniorrhaphy. Coala Trial Group Ann Surg (1997) 226(6):668–76. doi:10.1097/00000658-199712000-00004
29. Heikkinen, TJ, Haukipuro, K, and Hulkko, A. A Cost and Outcome Comparison Between Laparoscopic and Lichtenstein Hernia Operations in a Day-Case Unit. A Randomized Prospective Study. Surg Endosc (1998) 12(10):1199–203. doi:10.1007/s004649900820
30. Wellwood, J, Sculpher, MJ, Stoker, D, Nicholls, GJ, Geddes, C, Whitehead, A, et al. Randomised Controlled Trial of Laparoscopic Versus Open Mesh Repair for Inguinal Hernia: Outcome and Cost. Br Med J (1998) 317:103–10. doi:10.1136/bmj.317.7151.103
31. Paganini, AM, Lezoche, E, Carle, F, Carlei, F, Favretti, F, Feliciotti, F, et al. A Randomized, Controlled, Clinical Study of Laparoscopic vs Open Tension-Free Inguinal Hernia Repair. Surg Endosc (1998) 12:979–86. doi:10.1007/s004649900760
32. Jonsson, B, and Zethraeus, N. Costs and Benefits of Laparoscopic Surgery—A Review of the Literature. Eur J Surg Acta Chir Suppl (2000) 585:48–56. doi:10.1080/110241500750056553
33. Medical Research Council Laparoscopic Groin Hernia Trial Group. Cost-Utility Analysis of Open Versus Laparoscopic Groin Hernia Repair: Results From a Multicentre Randomized Clinical Trial. Br J Surg (2001) 88(5):653–61. doi:10.1046/j.1365-2168.2001.01768.x
34. Butler, RE, Burke, R, Schneider, JJ, Brar, H, and Lucha, PA. The Economic Impact of Laparoscopic Inguinal Hernia Repair: Results of a Double-Blinded, Prospective, Randomized Trial. Surg Endosc Other Interv Tech (2007) 21(3):387–90. doi:10.1007/s00464-006-9123-6
35. Gholghesaei, M, Langeveld, HR, Veldkamp, R, and Bonjer, HJ. Costs and Quality of Life After Endoscopic Repair of Inguinal Hernia vs Open Tension-Free Repair: A Review. Surg Endosc Other Interv Tech (2005) 19(6):816–21. doi:10.1007/s00464-004-8949-z
36. Heikkinen, T, Haukipuro, K, Leppala, J, and Hulkko, A. Total Costs of Laparoscopic and Lichtenstein Inguinal Hernia Repairs: A Randomized Prospective Study. Surg Laparosc Endosc (1997) 7:1–5. doi:10.1097/00019509-199702000-00001
37. Heikkinen, TJ, Haukipuro, K, Koivukangas, P, and Hulkko, A. A Prospective Randomized Outcome and Cost Comparison of Totally Extraperitoneal Endoscopic Hernioplasty Versus Lichtenstein Hernia Operation Among Employed Patients. Surg Laparosc Endosc (1998) 8(5):338–44. doi:10.1097/00019509-199810000-00003
Keywords: inguinal hernia repair, laparoscopic inguinal hernia repair, MIS hernia repair, OPP, open preperitoneal inguinal hernia repair
Citation: Blake K, Fullington N and Reinhorn M (2025) A Call to Change the Nomenclature of “Open” Inguinal Hernia Repair. J. Abdom. Wall Surg. 3:13868. doi: 10.3389/jaws.2024.13868
Received: 29 September 2024; Accepted: 09 December 2024;
Published: 03 January 2025.
Copyright © 2025 Blake, Fullington and Reinhorn. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Michael Reinhorn, bXJlaW5ob3JuQGJvc3Rvbmhlcm5pYS5jb20=