The American Journal of Surgery 193 (2007) 466 – 470

Clinical surgery–American

Advantages of laparoscopic transabdominal preperitoneal herniorrhaphy

in the evaluation and management of inguinal hernias
Yuri W. Novitsky, M.D.a,b,c,*, Donald R. Czerniach, M.D.b, Kent W. Kercher, M.D.c,
Gordie K. Kaban, M.D.b, Karen A. Gallagher, R.N.b, John J. Kelly, M.D.b,
B. Todd Heniford, M.D.c, and Demetrius E.M. Litwin, M.D.b
a
Department of Surgery, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-3955, USA
b
Department of Surgery, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 06105, USA
c
Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC 06050, USA

Manuscript received October 4, 2005; revised manuscript October 11, 2006

Abstract
Background: Laparoscopic transabdominal preperitoneal (TAPP) herniorrhaphy provides an opportunity
to definitively evaluate both inguinal areas without the need for additional dissection. We aimed to
establish the rates and contributing patient factors to errors in the preoperative assessment.
Methods: A retrospective review of consecutive patients undergoing laparoscopic TAPP herniorrhaphy at
2 tertiary-care centers. Preoperative history and physical examination were used to classify the presence of
hernia as “definite,” “questionable,” or “negative.” Any discrepancies between preoperative and intraop-
erative findings were viewed as errors in preoperative assessment.
Results: Two hundred sixty-two patients underwent 328 laparoscopic TAPP hernia repairs. Of the 283
hernias diagnosed as “definite” preoperatively, 276 were confirmed at operation (97.8%). An additional 19
of 173 (11.0%) clinically unrecognized hernias were repaired at the time of surgery. Overall, our approach
avoided unnecessary groin explorations and/or repairs in up to 16.4% patients and may have prevented
inappropriate delays of herniorrhaphy in up to 19.8% of patients. The sensitivity, specificity, and positive
predictive value of the clinical assessment of inguinal hernia were 94.5%, 80%, and 88.9%, respectively.
Symptom and/or examination findings of inguinal mass were the only significant independent predictor of
accuracy (P ⬍ .001).
Conclusion: A high rate of discordance exists between the preoperative clinical assessment and true
presence of inguinal hernias. Given the unique ability of laparoscopy to accurately evaluate the contralat-
eral side and the limited added morbidity of bilateral repair, TAPP herniorrhaphy is beneficial in avoiding
unnecessary explorations and allowing timely repairs in patients with occult inguinal hernias. © 2007
Excerpta Medica Inc. All rights reserved.

Keywords: Laparoscopic herniorrhaphy; Transabdominal preperitoneal; Asymptomatic inguinal hernia; Diagnostic

accuracy; Occult contralateral hernia

Approximately 500,000 to 750,000 hernia repairs are per- ideal opportunity to evaluate the contralateral side. Laparo-
formed in the United States each year. Although most hernia scopic confirmation of normal inguinal anatomy without
repairs are performed by using a variety of anterior ap- abdominal wall defects may avoid unnecessary anterior
proaches, laparoscopic inguinal herniorrhaphy may be as- groin explorations. In addition, identification and repair of
sociated with decreased postoperative pain and shorter con- an occult contralateral defect can mitigate the need for
valescence [1,2]. A laparoscopic approach is particularly subsequent herniorrhaphies should the patient become
suited for the repair of bilateral or recurrent hernias [3]. The symptomatic [2]. We hypothesized that there is a high rate
transabdominal preperitoneal (TAPP) approach provides an of error in preoperative evaluation of the contralateral in-
guinal area. In this study, we reviewed the surgeon’s pre-
* Corresponding author. Tel.: ⫹1-860-679-3955; fax: ⫹1-860-679-1202. operative clinical assessment for the presence of hernia and
E-mail address: novitsky@uchc.edu compared it with the operative findings. We also attempted

0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved.
doi:10.1016/j.amjsurg.2006.10.015
 Y.W. Novitsky et al. / The American Journal of Surgery 193 (2007) 466 – 470 467

Table 1 Statistical analysis

Type of discordance between preoperative clinical assessment and Sensitivity, specificity, and positive predictive value
intraoperative findings (gold standard) were used as measures of association to assess the validity
Discordance Preoperative Operative Patients, of the preoperative assessment compared with the laparo-
type assessment findings n (%) scopic diagnosis. For the purpose of calculating the sensi-
I Negative Positive 19 (7.3)
tivity and specificity, “questionable” and “definite” hernias
II Questionable Negative 36 (13.7) were grouped together. Univariate associations between cat-
III Definite Negative 7 (2.5) egorical risk factors and correct diagnosis were evaluated by
IV Questionable Positive 33 (12.6) using likelihood ratio chi-square tests (patient symptoms,
physical examination findings, and previous hernia repair).
Associations between correct diagnosis and dichotomous
risk factors (gender) were evaluated by using Fisher exact
to identify patient factors contributing to inaccurate preop- tests. Association between continuous risk factors (age and
erative groin assessment. BMI) and success outcomes was evaluated by using either a
Student t test or Welch-Aspin t test. Multivariate associa-
Patients and Methods tions between risk factors and success outcomes were eval-
After approval by an institutional review board, we per- uated by using multiple logistic regressions. Odds ratio
formed a retrospective review of consecutive patients un- estimates of relative prevalence were estimated by exponen-
dergoing laparoscopic TAPP herniorrhaphy at 2 high-vol- tiation of the coefficients fitted for the respective terms from
ume tertiary-care centers. All patients were referred for the logistic models.
probable inguinal hernia. Four experienced laparoscopic
hernia surgeons performed preoperative patient evaluations Results
and subsequent repairs. Based on the dictated office notes, The study population consisted of 262 consecutive pa-
each groin area was categorized as “definite,” “question- tients. The mean age was 47.9 years (range, 17– 82 years).
able,” or “negative” for the presence of a hernia. Typically, There were 18 (7%) women. The average BMI was 26.4 ⫾
hernias grouped as questionable were described as possible, 3.4 (range, 20 –38). There were 283 symptomatic hernias.
probable, or unclear. On the other hand, when a dictation Eighty-seven hernias (46 right and 41 left) had been previ-
described a hernia that was found or confirmed on a phys- ously repaired on at least one occasion. Preoperative indi-
ical examination, it was grouped as “definite.” In contrast, if cations for herniorrhaphy are summarized in Table 2. Three
a dictated note stated that a hernia was not found on exam- hundred twenty-eight hernias were identified during diag-
ination, it was grouped as “negative.” Intraoperative evalu- nostic laparoscopy and subsequently repaired using the
ation of the abdominal wall defects at the time of diagnostic TAPP approach. Preoperative assessment was correct in
laparoscopy was considered the gold standard. A defect in 182 of 262 (69.5%) patients evaluated. In the remaining 80
the area of Hasselbach’s triangle, seen as significant pro- patients, 1 (73 patients) or both (7 patients) sites were
lapse of the peritoneum, was considered a hernia. We did discordant. One patient with an inguinal mass and a pre-
not view minor dimples or small concavities in the perito- sumed “definite” hernia had no hernia identified on either
neum indicative of a significant hernia defect. Discordance side during a diagnostic laparoscopy. The discordance rates
was classified by type (Table 1). Patient characteristics, between preoperative assessment and operative findings are
including age, sex, body mass index (BMI), presenting summarized in Table 1.
symptoms, physical examination findings, and previous her-
nia repairs, were investigated as possible intrinsic factors
Presence of a hernia
contributing to the accuracy of the preoperative assessment.
A total of 524 inguinal regions were evaluated for the
The operative approach was similar, with only minor
presence of a hernia preoperatively. A “definite” inguinal
variations in technique, for all patients. General anesthesia
hernia was presumed to be present in 282 sites (130 right
was used in all cases. A 10-mm infraumbilical port was
and 152 left). Sixty-nine (40 right and 29 left) sites were
placed by using the Hasson technique, and diagnostic lapa-
“questionable”, and 173 were deemed to be “negative” for
roscopy was performed with patients in 10° to 20° Tren-
any defects. Of the 282 hernias diagnosed as “definite”
delenburg position. Once the diagnosis of an inguinal hernia
preoperatively, 276 (97.8%) were confirmed at operation. In
was confirmed, 2 accessory trocars were placed in the parar-
contrast, 19 of 173 (11.0%) clinically unrecognized (“neg-
ectus position. Superior and inferior peritoneal flaps were
then developed. Direct sacs and small indirect sacs were
fully reduced. Larger indirect sacs were often partially re- Table 2
duced before division and proximal ligation. The distal Preoperative surgical indications for herniorrhaphy based on clinical
portion of a large sac was sometimes left in situ. Medially, impression (n ⫽ 262)
the dissection was carried to the symphysis pubis. A large Surgical indication Patients, n
polypropylene mesh was implanted in all patients. The
mesh was placed along the symphysis pubis medially, Coo- Definite unilateral hernia 158
per’s ligament inferiorly, and beyond the internal ring lat- Definite bilateral hernias 40
Questionable unilateral hernia 13
erally. Tacking or stapling of the mesh was performed at the
Questionable bilateral hernias 6
surgeon’s discretion. The peritoneal flap was then fully Definite unilateral/questionable contralateral 44
reapproximated with either staples or running suture.
468 Y.W. Novitsky et al. / The American Journal of Surgery 193 (2007) 466 – 470

ative”) hernias were identified and repaired at the time of contralateral hernia. In our population, patients with a left-
surgery. Thus, the total discordance rate between definitely side hernia were no more likely to have an occult contralat-
present or absent hernia on preoperative evaluations and eral hernia than patients with a right-side hernia (odds ratio
intraoperative findings was 5.7% (26 of 457 hernia sites). Of 2.0, confidence interval ⫽ 0.66-6.44).
the 69 sites that were deemed to be “questionable” preop-
eratively, 33 (47.8%) sites were intraoperatively found to Comments
have a hernia with the remaining 36 (52.2%) sites to have no Laparoscopic TAPP hernia repair has the unique advan-
hernia defect. The sensitivity, specificity, and positive pre- tage of allowing simultaneous inspection of the contralateral
dictive value of the preoperative assessment in the diagnosis side during cases of unilateral hernia repair. This can benefit
of hernia were 94.5%, 80%, and 88.9%, respectively. the patient and prevent subsequent visits to the operating
Laparoscopic examination revealed hernias in all of the room [2]. Performance of a contralateral repair through the
“definite” unilateral group and in 92% of the “questionable” TAPP approach adds little extra discomfort and only mod-
unilateral group. Nineteen (7.3%) patients had a hernia estly increases operative time over unilateral repair. One
defect discovered only at the time of laparoscopy. Seven prospective study compared the sensitivity and specificity of
(2.5%) patients with a presumed “definite” hernia were clinical examination, ultrasonography, and diagnostic lapa-
found to have no defect. As a result, assuming that all roscopy in the preoperative diagnosis of inguinal hernias in
“questionable” hernias would have undergone an attempted 30 adult patients with suspected hernias or chronic groin
open repair, 16.4% (43 of 262) patients may have had an pain [4]. Although clinical examination was more accurate
unnecessary groin exploration. On the other hand, if all than ultrasonography, diagnostic laparoscopy achieved the
“questionable” hernias were observed, the repair may not highest sensitivity (93%) and specificity (100%) [4]. Even
have been performed in 19.8% (52/262) of patients under- with recent reports of high sensitivity and specificity of
going a unilateral open herniorrhaphy. groin ultrasonography [5,6], direct visualization of the con-
Sixty-seven (25.6%) patients were found to have a bilat- tralateral Hasselbach’s triangle during a laparoscopic
eral hernia intraoperatively. Thirty-three of those patients TAPP, we believe, remains to be most accurate. Further-
had “definite” bilateral hernias according to the clinical more, even surgeons who prefer a laparoscopic totally ex-
impression. Three patients had a preoperative diagnosis of traperitoneal (TEP) approach for hernia repair may prefer-
“questionable” bilateral hernias, and another 12 patients had entially perform diagnostic laparoscopy before proceeding
a “definite” unilateral and a “questionable” contralateral with extraperitoneal balloon dissection [4,7]. The TAPP
defect. In the remaining 19 patients with bilateral hernias, approach eliminates the need for additional dissection and
only 1 side was diagnosed preoperatively. Intraoperative minimizes the risk of inadvertent spermatic cord injury.
findings of 90 patients with preoperative impression of Few studies have investigated this diagnostic advantage
bilateral inguinal hernias are summarized in Table 3. Forty- of laparoscopic hernia repair. Panton and Panton [8] found
two patients would have undergone an unnecessary explo- that 25% of patients undergoing TAPP hernia repair were
ration of one of the inguinal areas if an open herniorrhaphy diagnosed with contralateral hernias intraoperatively. Sim-
was chosen. ilarly, Crawford et al. [7] reported that 50% of patients
thought to have unilateral hernias exhibited bilateral hernias
Risk factors leading to discordance during TEP. Overall, a little over a quarter of our patients
The factors found to be independent predictors of accu- were found to have bilateral hernias at the time of laparos-
rate diagnosis of inguinal hernia (defined as “definite” or copy. This, importantly, includes more than 10% of patients
“questionable” in the preoperative impression with a con- thought to have unilateral hernias by clinical impression and
firmed intraoperative hernia or a “negative” preoperative subsequently found to have previously unrecognized occult
impression and no intraoperative hernia) was the symptom contralateral defects.
of inguinal mass (P ⬍ .0001) and the finding of inguinal Although the intraperitoneal view achieved during diag-
mass on physical examination (P ⫽ .002). All other vari- nostic laparoscopy and subsequent TAPP repair allows an
ables tested including age, sex, physical examination find- accurate assessment of all three hernia orifices and the
ings, BMI, and history of previous hernia repair did not overlying peritoneum, certain circumstances can exploit the
independently influence the accuracy of the preoperative limitations of this technique. One such situation is a large
assessment. cord lipoma masquerading as an indirect hernia. Gersin
The presence of a left-side hernia was studied indepen- et al. [9] described 6 patients with no identifiable hernia
dently as a predictor of an asymptomatic and unrecognized defects on diagnostic laparoscopy found to have spermatic

Table 3
Intraoperative findings in patients with a preoperative definite/questionable clinical impression of bilateral inguinal hernias
Preoperative assessment/intraoperative Definite bilateral Questionable bilateral Definite unilateral/questionable
findings hernias hernias contralateral hernias
n ⫽ 40 n⫽6 n ⫽ 44 Total n ⫽ 90

Bilateral hernia 33 3 12 48
Unilateral hernia 7 3 32 42

Forty-two patients would have been unnecessarily explored if an open approach was chosen.
 Y.W. Novitsky et al. / The American Journal of Surgery 193 (2007) 466 – 470 469

cord lipomas that protruded from the internal ring after study, several predictors of a successful clinical diagnosis
creation of the inferior peritoneal flap. They concluded that were detected. We found that the symptom of inguinal mass
all patients with a documented mass in the inguinal canal on and the finding of an inguinal mass on physical examination
physical examination should undergo obligatory exploration were statistically significant independent predictors of an
of the internal ring and cord structures, even when no defect accurate preoperative diagnosis of inguinal hernia irrespec-
is visualized laparoscopically. In the current series, we en- tive of side. Furthermore, we found that patients with a
countered 1 patient with an inguinal mass on examination diagnosis of unilateral hernia when the contralateral side is
who had no defect discovered on diagnostic laparoscopy. determined to be either negative or suspicious on examina-
Contrary to our present strategy, the procedure was aborted tion could benefit from a laparoscopic repair because 25.6%
before a preperitoneal dissection was attempted. A second of them showed bilateral defects on laparoscopic examina-
diagnostic dilemma unique to TAPP may be the inability to tion. Overall, laparoscopic examination detected more
identify very small hernia defects that fail to cause eventra- cases of bilateral hernia than clinical examination alone.
tion of the overlying peritoneum. This may explain the The sensitivity and specificity of the clinical impressions
higher incidence of bilateral hernias in the TEP literature [7] reported here indicate that clinical examination of hernia
compared with the TAPP literature [10 –12]. It remains alone is not a very reliable indicator of bilateral disease.
unclear whether diagnostic laparoscopy truly underesti- In our population undergoing laparoscopic repair, no
mates the presence of relevant defects or whether a total patient underwent an unnecessary contralateral groin ex-
extraperitoneal dissection without diagnostic laparoscopy ploration.
overestimates the number of clinically significant hernias. Asymptomatic inguinal hernias have recently been as-
Further studies on the natural history of these incidental sessed in a randomized prospective trial by Fitzgibbons
defects are therefore warranted. et al. [15]. The authors evaluated 724 patients, with 366
The mere presence of a left inguinal hernia has been assigned to the “watchful waiting” group. They found that
suggested as an independent risk factor for the discovery of 23% of patients crossed over to the “repair” group because
an occult right inguinal hernia at the time of laparoscopic of the increased groin symptoms within the first 2 years.
exploration. This finding is likely attributed to the embryo- Although watchful waiting strategy appeared to be safe,
logical development of the processus vaginalis and the fact given a very low rate (0.3%) of acute complications, it
that the right side obliterates later in development. In a large appears that a significant proportion of the patients managed
meta-analysis of the pediatric population, the risk of meta- nonoperatively require a herniorrhaphy fairly early on [15].
chronous hernia was 50% greater if the clinically apparent In another study, Thumbe and Evans [16] followed 21
hernia was on the left side as opposed to the right side [13]. patients found to have an occult contralateral hernias during
One study in the adult literature also supports this relation- a TAPP repair of the ipsilateral side. They found that over
ship with prevalence rate ratios of 2.2 [14]. This relationship a short follow-up of 12 months, 28% of patients developed
did not hold true in our study population in which there was symptoms severe enough to require repair. The authors
no difference between the left and right sides with regard to noted that several of the defects, which had appeared small
the discovery of occult contralateral hernias. initially, had enlarged significantly in the interim [16]. Al-
The retrospective nature of this study limited our ability though this prospective trial has small number of patients
to clearly determine the degree of surgeons’ suspicion re- and relatively short follow-up, it may lend further evidence
garding hernia presence. To highlight the salient advantage that many of the occult hernias will fail nonoperative man-
of laparoscopic over traditional open herniorrhaphy, we agement. Overall, given the simplicity of contralateral in-
chose to compare our series with a hypothetical group of guinal evaluation and the limited added risks of bilateral
patients undergoing an open hernia repair. For the purposes TAPP repair, we currently favor repair of all contralateral
of this comparison, we first made a priori assumption that all occult defects identified during surgery. We believe that this
questionable hernias would have been explored in the hy- practice may avoid the need for subsequent interventions in
pothetical open cohort. It appears that 43 (16.4%) patients patients with progressive symptoms without significant
(7 with “definite” and 36 with “questionable” hernias) added morbidity. We carefully council our patients regard-
would have had unnecessary explorations in the hypotheti- ing this strategy and obtain an informed consent during a
cal open group. Furthermore, of the 67 bilateral hernias preoperative evaluation. Additionally, confirmation of pre-
confirmed intraoperatively, 100% were discovered and re- operatively identified defects may be accomplished laparo-
paired by the TAPP approach. In contrast, 19 occult con- scopically through a small periumbilical access incision.
tralateral hernias would have been missed in the hypothet- This possibility appears to offer further advantage of TAPP
ical open cohort. In addition, if a priori assumption implied over open repairs because definitive assessment for the pres-
that all questionable defects were to be observed, 52 ence or absence of a hernia defect in the latter approach is not
(19.8%) patients in a hypothetical open group would not available until an anterior groin exploration is performed.
have had a timely repair. It appears that laparoscopic ap-
proach may be particularly beneficial in patients with only
questionable preoperative evidence of a hernia as those Conclusion
patients managed by TAPP experienced no missed occult Preoperative physical examination of the inguinal canal
contralateral hernias and no unnecessary explorations. has significant limitations even for experienced surgeons. A
Because of its inherent accuracy, laparoscopic intraop- high rate of discordance exists between the preoperative
erative diagnosis provides a good tool for assessing poten- clinical impression and the true presence of inguinal her-
tial risk factors for bilateral inguinal hernia. In the present nias. Diagnostic laparoscopy and subsequent laparoscopic
470 Y.W. Novitsky et al. / The American Journal of Surgery 193 (2007) 466 – 470

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