TEP can be done very comfortably under epidural anesthesia.It is better to do balloon dissection to create space rather than scope dissection.Scope dissection may cause small peritonial tears.We have done under regional local block as well.

Interesting. Do you use epidural or spinal anesthesia in that case? And do you have series that show in how many cases you have to "convert" to general anesthesia?

All TEP procedures require some degree of dilatation. That is very unconfortable. in some cases scrotum is dilated because pf CO2. Regional anesthesia, besides is proven to be unsafer, would be very unpleasant for the patient. We strive for patient safety and confort and I cant think of a justification to perform TEP prpcedures under regional anesthesia.

Those cases which are not suitable due to severe copd or cardiac problems were done

but not as a routine.In our series of 13 cases spanning over a period of 7 years(Not published as the numbers are small).Regional anaesthesia is always spplememented with IV sedation.If the hernia is not inguino scrotal and if the surgeon is experienced,it is not unpleasant or unsafe for the patient.We noticed small peritoneal tear in one pt but

completed the proceedure.Average time taken in these cases is 30 to 45 mts.Only one case we did it under local block, 1year review No recurrence.size of the mesh used is 15 x 12.only one fixation to the pubic tubercle with tack.

Why couldn't the cases with COPD or cardiac problems be done with Lichenstein technique?

In this part of the Globe pt"s pay for their treatment.Most of the families have an access to internet.So we explain about the open option first , incase if a conversion is required.Ours is the largest territiory care centre ,hence pt"s expectations are high.Our personnel experience is pt's fair better with TEP eventhough it is not evidence based.

Of course Lichtenstein can be done perfectly. It is our second-best option after TEP. However, neuralgia is supposed to be way less with TEP (Eklund, BJS 2010, Kehlet, BJA 2005). In patients with a contra-indication for general anesthesia (COPD or cardiac problems) it is our first choice at the moment. but I agree with Prasanna Kumar Reddy that patients with TEP do recover faster (as stated in the european guideline published in Hernia 2009).

Therefore my question if it would be possible to treat these patients also with regional anesthesia. And would spinal anesthesia not be more logical than epidural anesthesia? At what level is the puncture performed?

Good debate initiated by Dr. Heemskerk.

The biggest problem I suppose is the respiratory difficulty due to a steep 'head down' patient position. In spite of all the individual responses to this question, there is extensive published literature suggesting the feasibility of TEP under regional anesthesia.

Examples of published literature:

1. Katkhouda. In: Arregui ME, Nagan RF, editors. Inguinal hernia. Advances or controversies. New York: Radcliffe Medical Press 1994:89-93.

2. Spivak, et al. Surg Endosc 1999;13:1026 –1029.

3. Cartagena, et al. J Ambul Surg 2003;10:55-59.

4. Chowbey, et al. Surg Laparosc Endosc Percut Tech 2003;13: 185–190.

5. Lau, et al. J Laparoendosc Adv Surg Techn 2005;15:121-124.

6. Zacharoulis, et al. Am J Surg 2009;198:456-459.

Local anesthesia:

7. Ferzli, et al. Surg Endosc 1999;13:588–590.

I have never seen or heard of any one of my colleagues doing it under Epidural or spinal. You do need to get good extraperitoneal space. Trying to stretch the abdominal muscles under regional, I am sure would be very painful. If a patients has significant co-morbidites, why do the operation under regional why not under LA one side at a time, as I do. It was the very reason why I started the First Walk in Walk Out hernia clinic in the NHS as an old patient of mine with very significant co morbidities could not be given GA or Regional anaesthesia. I agree with Juan Carlos. 

Also it should not be the second best option, but the first option in such patients. 

My policy is just because you can do an operation laparoscopically does not mean that you must do it in every case. I feel patient selection is the most important thing for any surgical intervention. 

Very interesting discussion. I use both the Lichtenstein under LA/GA and TEP under GA for my patients and have never considered doing the latter under regional anaesthesia. I would contend that the main benefit of TEP (one week quicker return to normal activity) is less likely to be realised in an individual that is not fit enough for a GA (regardless of age), hence I tend to offer LA repair to those patients. Furthermore, there are definite health economical reasons why TEP might not be the best solution for such patients.

we performed a pilot of several patients performing TEP under spinal anesthesia. However, this was not comfortable for the patients and we often had to add general anesthesia. This is probably due to CO2 leakage after (small) peritoneal tear, resulting in intra-abdominal pressure and difficulties in relaxation and breathing. Therefor we allways use  general anesthesia.

very interesting. I also have some experience performing TEP hernia repair under spinal anaesthesia in selected patient who general anaesthesia is contraindicated. i didn't feel the different between both methods. here is the link of my own video of bilateral TEP under spinal anaesthesia in moderately severe asthma patient. 

https://www.youtube.com/watch?feature=player_detailpage&v=3xrRoPjZ1L0

http://www.ncbi.nlm.nih.gov/pubmed/18803509

I am sure it is feasible to doTEEP for Bilateral inguinal under spinal anaesthesia. I have done just one since this discussion started. i will report howmy experience goes. Only disadvantage I found was not being able to have the head of patient down but it was not as bad as I thought.

Please try e TEP ,very comfortable but do it under spinal after familiarising with the proceedure .