Sutureless laparoscopic extraperitoneal inguinal herniorrhaphy using reusable instruments: two hundred three repairs without recurrence.

Laparoscopic extraperitoneal hernia repair has several distinct advantages over the anterior repair and the laparoscopic transabdominal preperitoneal method. Laparoscopic extraperitoneal hernia repair allows detection and repair of occult contralateral defects with minimal risk of intraabdominal injury or adhesion formation and is associated with less pain and a quicker recovery. However, there are disadvantages. Circumferential mobilization of the spermatic cord and the use of staples to secure the mesh have been associated with injury to the spermatic cord and nerves. The cost of the laparoscopic approach is higher than that of open herniorrhaphy. Additionally, it is more difficult to do because there is a poor understanding of the preperitoneal fascial anatomy. A method of totally extraperitoneal inguinal herniorrhaphy emphasizing anatomic dissection and landmarks is described. The authors use only reusable instruments, no balloon dissector, and no fixation of the mesh. The wide dissection of the myopectineal orifice allows placement of a large mesh and utilizes intraabdominal pressure alone to secure the mesh on the posterior aspect of the abdominal wall, as described by Stoppa et al. (1). Operative costs are minimized. From experience with 203 sutureless extraperitoneal repairs, a low incidence of complications and no recurrences are demonstrated. It is extrapolated that the cost of this laparoscopic repair will approximate more closely that of open anterior herniorrhaphy.