This is a question I get often asked by my patients, and my reply is usually: it depends. This depends on: is it possible to have laparoscopic (keyhole) repair or not and whether you prefer to have one over another.
There are several reasons why a surgeon may not be able to perform laparoscopic inguinal hernia repair:

1. They are not trained on how to do this - this is very rare these days. Most surgeons have been trained on how to do these surgeries, but there are still few who do not do them. This does not mean that these surgeons are not good at performing laparoscopic surgery or open inguinal hernia repair. At some stage, they decided that they do not wish to learn this procedure. If you really want to have a laparoscopic inguinal hernia repair and your surgeon does not perform this procedure, then you should ask your surgeon to refer you to a specialist who does perform it.

2. Due to previous surgeries, it is not possible to perform a laparoscopic repair. This is the most common reason for surgeons to decide against keyhole repair. If you have had a previous laparoscopic inguinal hernia repair on the same side, then you are not able to have it again. If you have had open prostate surgery, iliac vessels surgery, iliac lymph node removal surgery on the same side as hernia, it is unlikely that laparoscopic repair will be successful or attempted. The reason for this is that the space between the lining of your stomach cavity (peritoneum) and behind the abdominal wall muscles has been used for access to those organs and it is completely scared and stuck together. And this is a space needed to be able to perform inguinal hernia repair.

3. Severe obesity - any repair in this situation is challenging. The reason for this is that abdominal wall fat over the muscles are so heavy that keeping the space between the peritoneum and abdominal wall musculature requires extremely high gas pressures or space is not able to be developed. This has happened only once for me in a person who was around 150kgs in weight. I had to do an open procedure, and this was very difficult as well.

In general risks of laparoscopic and open hernia repairs are similar, but there are few differences.

Similar:

• The risk of hernia recurrence following both repairs is 2-5%

• Risk of infection is very rare for both repairs, less than 1% (higher in patients with obesity and/or diabetes)

• Bleeding is rare with both procedures. We used to talk about the injury to femoral vessels being more common with laparoscopic repair, but this was only in the early days.

• Mesh is used both in laparoscopic as well as in open inguinal hernia repairs. More information about this is in my blog on the use of mesh in hernia repairs

Laparoscopic repair better than open:

• Pain following repair is more common with open repairs. Rates of both post-operative pain, as well as chronic pain, are lower in laparoscopic repair. The reason for this is that the open operation is performed in the area where sensory nerves are more exposed to injury or become incorporated in mesh and scarring related to the mesh. The laparoscopic surgery is not performed in the same space, so the nerves are not directly exposed to mesh incorporation or injury. This can happen if the mesh is secured at the sides, rather then just in the middle.

• people usually return back to work or sports earlier with laparoscopic than open repair.

Open repair is better than laparoscopic:

• The risk of bowel injury is usually lower in the open than laparoscopic repair.

• The risk of small bowel adhesions is rare in both procedures, but slightly more common in laparoscopic repair. This is when a piece of mesh becomes exposed to the small bowel and can lead to surgery in future.

In the end, the surgeon should tell you whether they think that laparoscopic surgery is possible or not and what are their risks of conversion to open procedure. They should be able to tell you what the risks and benefits of both procedures in their hand are. After this, you decide which surgery you would prefer to have.

If you and your surgeon do not agree on the type of procedure performed, you should ask for a second opinion. Neither you nor your surgeon should be pressured to perform/have surgery that you/they no wish to have/do.