title: Which should be the gold standard laparoscopic technique for handling Spigelian hernias?
abstract: BACKGROUND
  The advantages and disadvantages of both extraperitoneal and intra-abdominal laparoscopic Spigelian hernia repair are still being discussed. To our knowledge, no study has compared both techniques in terms of safety, feasibility, and cost-effectiveness.
  
  
  METHODS
  Prospective data were collected to compare the results of the extraperitoneal approach with the intra-abdominal approach in laparoscopic Spigelian hernia repair, between 2000 and 2012 (n = 16). Diagnosis was confirmed preoperatively by ultrasonography and/or tomography.
  
  
  RESULTS
  Spigelian hernias occur mostly in women (69 %), on the left side (56 %) and at a median age of 62 (range: 38-83). In our study, the extraperitoneal technique was performed in seven patients, while the intra-abdominal approach was indicated in nine. No complications, re-admissions, or recurrences were detected in either during a mean follow-up of 48 months (range: 18 months-9 years). The statistical study showed that there was no difference in either morbidity or the recurrence rate between a totally extraperitoneal (TEP) and an intraperitoneal onlay mesh (IPOM) repair. The mean duration of an IPOM repair was, though, shorter than that of a TEP repair (30 vs. 48 min, P = 0.06). The combined fixation technique (tacks + glue) did not modify the results but did reduce the costs, as shown in the cost-effectiveness study where the intra-abdominal approach was cheaper (1260 vs. 2200 euros, P < 0.001).
  
  
  CONCLUSIONS
  Laparoscopy seems to be a safe and feasible technique whichever the approach chosen, be it intra or extraperitoneal. Our experience shows that intra-abdominal laparoscopic Spigelian hernia repair should be recommended as the gold standard because of its technical and economic advantages. The IPOM procedure with a lightweight titanium-coated mesh fixed using a combined technique is a highly effective option for Spigelian hernia repair.
authors: Abdominal Wall Unit, Department of Surgery, Morales Meseguer University Hospital, Avda Primo de Rivera 7, 5ºD, 3008, Murcia, Spain, morenoegeaalfredo@gmail.com.
authors: Alfredo
authors: A
authors: Moreno-Egea
authors: Álvaro
authors: Á
authors: Campillo-Soto
authors: German
authors: G
authors: Morales-Cuenca
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006555:Hernia, Ventral / Q000191:economics / Q000601:surgery*; D059685:Herniorrhaphy / Q000191:economics / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000191:economics / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D013030:Spain; D016896:Treatment Outcome