1. Laparoscopic inguinal herniorrhaphy PROS AND CONS George Ferzli MD, FACS Professor of Surgery SUNY Downstate

2. Where is the controversy?

3. Only open hernias can be done with spinal or local anesthesia

4. But then:

5. But then:

6. Recurrent hernias cannot be repaired via laparoscopy

7. But then: Laparoscopic preperitoneal repair of recurrent inguinal hernias P. Sayad, G Ferzli J Laparoendosc Adv Surg Tech A 9:127-130 (1999)

8. Then the instruments became smaller Surg Endosc 13:822-823 (1999) © 1999 by Springer-Verlag New York, Inc. Needlescopic extraperitoneal repair of inguinal hernias G. Ferzli, P. Sayad, J. Nabagiez

9. Scrotal hernias cannot be repaired laparoscopically

10. But then:

11. Another advantage of laparoscopy:

12. Recurrences after a laparoscopic inguinal hernia repair must be done via an open approach

13. But then:

14. What do the prospective randomized studies show?

15. Mesh infection 0.08% Bladder injury 0.1% Bowel injury 0.1% Neuralgia 0.1% TEP 1182 Ferzli/2002 Mesh infection 0.02% Hematoma 1.8% Neuralagia 0.3% TEP 5203 Tamme/2003 Recurrence 0.7% Conversion 0.1% Bleeding 0.5% Mesh infection 0.1% Trocar site hernia 0.7% Nerve injury 0.3% Bladder injury 0.1% Bowel injury 0.1% TAPP 8050 Bittner/2002 Recurrence 0.4% TAPP 5163 TEP 4890 10053 Felix/1998 Complications TAPP vs. TEP N=Hernias Author/Year

30. Swanstrom. Surg Clin N Am. 2000; 80 :1341

31. Swanstrom. Surg Clin N Am. 2000; 80 :1341

33. Outcome Measures

35. … but where is the greatest impact of the learning curve?

37. Resident Experience in Cholecystectomy

38. Resident Experience in Hernia Repair

42. Given the data regarding training experience, we can only conclude that our graduating residents are not beyond the learning curve.

43. In order for lap inguinal hernia results to be equal to open hernia, surgeons must be beyond their own learning curve