laparoscopic inguinal hernia repair eminence-based or evidence-based?

LAPAROSCOPIC INGUINAL HERNIA REPAIR

George Ferzli, MD, FACSGeorge Ferzli, MD, FACS

Eminence-based….or Evidence-based?

Bernhardt GA et al: Do We Follow Evidence-Based Medicine Recommendations During Inguinal Hernia Surgery? Results of a survey covering 2441 hernia repairs in 2007. World J Surg (2009) 33:2050-2055.

Survey of 15 surgical departments

in Styria, Austria to determine whether

hernia surgeons follow evidence-based

medicine criteria in their daily routine.

Oxford center for evidence-based medicine

Levels of evidence1A Systematic review of RCTs with consistent results from individual

(homogenous) studies.1B RCTs of good quality.2A Systematic review of cohort or case-control studies with consistent

results from individual (homogenous) studies.2B RCT of poorer quality or cohort or case-control studies.2C Outcome studies, descriptive studies.3 Cohort or case-control studies of low quality.

Expert opinion, generally accepted treatments.

Grades of recommendationA Supported by systematic review and/or at least 2 RCTs of good quality

Level of evidence 1A, 1BB Supported by good cohort studies and/or case control studies

Level of evidence 2A, 2BC Supported by case series, cohort studies of low quality and/or

‘outcomes’ researchLevel of evidence 2C, 3

D Expert opinion, consensus committeeLevel of evidence 4

What are the diagnostic modalities for inguinal hernia?

Level 2C• Clinical examination suffices for evident hernia.• Differentiation between direct and indirect hernia is NOT useful. Obscure pain/doubtful groin swelling requires further diagnostic investigation.• Ultrasonography – sensitivity and specificity are too low.• CT scan – limited use for diagnosis. • MRI – has sensitivity and specificity > 94% and is also useful to reveal other musculo-tendineal pathology.• Herniography – has high sensitivity and specificity in unclear diagnosis but low incidence of complications (does not reveal lipomas of the cord).

RecommendationsGrade C• Groin diagnostic investigations are performed only in patients with obscure pain and/or swelling. The flow chart for these cases:- Ultrasound (if expertise available)- If ultrasound negative; then MRI (with valsalva)- If MRI negative; consider herniography

European Hernia Society Guidelines: Treatment of Inguinal Hernia in Adult Patients

What are the indications for surgical treatment?Can non-surgical treatment be considered?

Level 1B• Watchful waiting is an acceptable option for men with minimallysymptomatic or asymptomatic inguinal hernias.Level 4• A strangulated inguinal hernia (with symptoms of strangulation and/orileus) should be operated on urgently.

RecommendationsGrade A• It is recommended in minimally symptomatic or asymptomatic inguinalhernia in men to consider a watchful waiting strategy.Grade D • It is recommended that strangulated hernias are operated on urgently.• It is recommended that symptomatic inguinal hernias are treated surgically.


What are the risk factors and prevention?

Level 3Smokers, patients with positive family hernia history, patent processusvaginalis, collagen disease, patients with an abdominal aortic aneurysm,after an appendicectomy and prostatectomy, with ascites, on peritonealdialysis, after long-term heavy work or with COPD have an increased risk of inguinal hernia. This is not proven with respect to (occasional) lifting, constipation and prostatism.

RecommendationGrade CSmoking cessation is the only sensible advice that can be given withrespect to preventing the development of an inguinal hernia.


What are indications for laparoscopic inguinal hernia repair?

Recurrent hernia• Avoids scar tissue• Visualizes occult hernia

Bilateral hernia• Decreased pain • Earlier return to work• No difference in recurrence or complication

Obese / Athletic patients• Definitive diagnosis• Reduced infection in susceptible population• Gilmore’s groin

Patients with contralateral injury to vas deferens• Less chance to injure other vas

Are there contraindications to lap. inguinal hernia repair?

Contraindications• Patients for whom general anesthesia and

pneumoperitoneum are risks (cardiac, pulmonary disease)

Relative Contraindications• Prior pre-peritoneal surgery (prostate, hernia, vascular,

kidney transplant)• Prior laparotomy• Ascites• Strangulated hernia• Giant scrotal hernia• Anticipated bleeding (patients on anti-coagulation)

How should an inguinal hernia be treated?

Level 2AFor endoscopic inguinal hernia techniques, TAPP seems to be associated with higher rates of port-site hernias and visceral injuries while there appear to be more conversions with TEP.

Level 2BThere appears to be a higher rate of rare but serious complications with endoscopic repair especially during the learning curve period

Level 1AOperation techniques using mesh result in fewer recurrences thantechniques which do not use mesh.Endoscopic inguinal hernia techniques result in a lower incidence of wound infection, hematoma formation and an earlier return to normal activities or work than the Lichtenstein technique.Shouldice repair is the best non-mesh open repair.

Cochrane Database 2009 Moia AB et al (4):CD001543

What are the recommendations for inguinal hernia repair in female patients?

Inguinal hernia in womenLevel 2C• Women have a higher risk of recurrence (inguinal or femoral) than men following an open inguinal hernia operation due to a higher occurrence of femoral hernias.

RecommendationsGrade D• In female patients, existence of a femoral hernia should be excluded in all cases of a hernia in the groin.• A preperitoneal (endoscopic) approach should be considered in female hernia repair. (Ferzli: It is not necessary to divide the round ligament in the endoscopic repair)


Crawford found an incidence of 8% occult femoral hernia at laparoscopic repair,

and Felix found 9% concurrent femoral hernia.Felix 1996 Recurrent Primaryn = 152 patients Femoral 9% 4%n = 173 recurrent hernias Pantaloon 25% 14%

Chan’s series of 225 repairs of femoral hernia repairs demonstrated 50.9% had

concurrent Inguinal hernia

5.8% had bilateral femoral hernia and 18.2% had prior groin hernia repair.

Chan believes prior inguinal hernia repair may precipitate a femoral hernia (15 x

higher according to Mikklesen etal).

Bisgaard 2008 Repair type Femoral recur. Re-recurrence Rate

n = 2,117 re-operations Endoscopic rep. n = 34 0.00% Open repair n = 161 8.07%

TAPP allows full visualization of the floor and avoids missed concomitant ipsilateral or contralateral hernias.

Femoral hernia

Femoral Hernia

• 3,980 femoral hernia repairs from Swedish Hernia Register

• 1,490 men, 2,490 women

• 35.9% (n = 1,430) underwent emergency surgery versus 4.9% of inguinal hernia repair

• Bowel resection - 22.7% of emergent femoral repair versus 5.4% of emergent inguinal repair

• Women at higher risk than men (40.6% versus 28.1%)

• Mortality 10 times greater versus elective repair

Dahlstrand UD, Wollert S, Nordin P, Sandblom G, Gunnarsson U. Emergency femoral

hernia repair A Study based on a national register. Ann Surg 2009; 249: 672-676.

What are the recommendations for lateral inguinal hernia in young men (18-30 years)?

Level 2BA young man (18-30 years) with a lateral inguinal hernia has a risk of recurrence of at least 5% following a non-mesh operation and a long follow-up (> 5 years).

RecommendationGrade BIt is recommended that a mesh technique is used for inguinal hernia correction in young men (18-30 years), irrespective of the type of inguinal hernia) Lateral hernia has a higher chance of recurrence when compared to a direct one. it has been widely accepted that medial hernias, especially those presenting as broad direct bulges, are 10 times less prone to be strangulated than lateral hernia

Fujita T. The procedure of choice for recurrent inguinal hernia. Ann Surg 2008; 248: 347-348. Schumpellick V, Treutner KH, Arlt G. Inguinal hernia repair in adults. Lancet 1994; 344: 375-379.European Hernia Society Guidelines: Treatment of Inguinal Hernia in Adult Patients

Antibiotics and thromboembolic prophylaxis

Montgomery, A; Perioperative management: What is the evidence for antibiotic and thromboembolic prophylaxis in laparoscopic inguinal hernia operation? Malmo University Hospital, Sweden

Grade 5

There is insufficient evidence to state that routine antibiotic prophylaxis is indicated in laparoscopic hernia surgery.

There is insufficient evidence to state that routine thromboembolic prophylaxis is indicated in laparoscopic hernia surgery.

Table 1: RCT comparing prophylactic versus non-prophylactic antibiotics in inguinal hernia surgery

Montgomery, A. Perioperative management: What is the evidence for antibiotic and thromboembolic prophylaxis in laparoscopic inguinal hernia operation? Malmo University Hospital, Sweden

Author Profylax Infected Non- Infected RRA NNT Level ofTotal n profylax profylax Non- CI 95% evidence

Total n profylaxOpen hernia surgery included in Coharane Evans 1973 (16) 48 2.1 % 49 4.1 % 2.0 (-4.9, 8.9) 50 2 bAnderson 1980 (17) 137 3.6 % 150 4.0 % 0.4 (-4.1, 4.7) 285 2 bPlatt 1990 (18) 301 1.3 % 311 1.9% 0.6 (-1.4, 2.6) 167 1 bLazhortes 1992 (19) 155 0 % 153 4.6 % 4.6 (1.2, 7.9) 22 2 bTaylor 1997 (20) 283 8.8 % 280 8.9% 0.1 (-4.6, 4.7) 1057 1 bMorales 2000 (21) 237 1.7 % 287 2.1 0.4 (-1.9, 2.7) 248 1 bYerdel 2001 (22) 136 0.7 % 133 9.0 % 8.3 (3.2, 13.4) 12 2 bOteiza 2004 (23) 124 0.8 % 123 0 % -0.8 (-2.4, 0.7) -124 1 bAufenacker 2004 (24) 475 1.7 % 472 1.9 % 0.2 (-1.5, 1.9) 449 1 bCeldan 2004 (25) 50 0 % 49 8.1 % 8.2 (0.5, 15.8) 12 2 bPessaux 2005 (5) 2008 3.4 % 394 5.1 % 1.7 (-0.6, 4.0) 59 2 bPerez 2005 (26) 174 1.7 % 176 3.4 % 1.7 (-1.6, 5.0) 59 1 bTotal 4128 2.9% 2577 3.9 % 1.1 (0.2, 2.0) 92

Laparoscopic hernia surgery not included in CochraneSchwetling 1998 (14) 40 0 % 40 0 % ns 2 b

Open hernia surgery not included in CochraneTzovaras et al 2007 (15)193 2.6 % 193 4.4 % p = 0.4 2 b

Table 2: RCT comparing laparoscopic versus open inguinal hernia surgery with infectious complications as a secondary endpoint.

Montgomery, A. Perioperative management: What is the evidence for antibiotic and thromboembolic

prophylaxis in laparoscopic inguinal hernia operation? Malmo University Hospital, Sweden

(?= antibiotic profylax given or not is not reported)

Author Name AB N Lap Lap Open Open n Country prof. Total group inf group inf

Liem Coala ? 994 487 0 % 507 1.2 % 0.031997 (6) Netherland TEP OptionalMRC MRC ? 928 468 2.8 % 460 3.1 % ns1999 (7) UK TEP, TAPP Optional Berndsen

SMIL I No 1042 518 0.8 % 524 0.8 % ns2002 (8) Sweden TAPP ShouldiceNeumayer AV ? 1983 989 1.0 % 994 1.4 % ns2004 (9) USA TEP, TAPP LichtensteinEklund SMIL II No lap 1371 665 1.4 % 706 0.7 % 0.212006 (10) Sweden Yes open TEP Lichtenstein

Total 6318 3127 1.2% 3191 1.3%

Antibiotics and thromboembolic prophylaxis

Montgomery, A; Perioperative management: What is the evidence for antibiotic and thromboembolic prophylaxis in laparoscopic inguinal hernia operation? Malmo University Hospital, Sweden

Level D

Antibiotic prophylaxis for elective laparoscopic inguinal hernia repair cannot be universally recommended.

Antibiotic prophylaxis is to be given in the presence of risk factors for wound and mesh infection based on patient (advanced age, corticosteroid usage, immunosuppressive conditions and therapy, obesity, diabetes and malignancy) or surgical complications (contamination, long operation time, drainage, urinary catheter)

Thromboembolic prophylaxis is to be given according to usual routines in patients with risk factors.

Should inguinal hernia repair be done as day surgery?

Level 2BInguinal hernia surgery as day surgery is as safe and effective as that in an inpatient setting, and more cost-effective.

Level 3Inguinal hernia surgery can easily be performed as day surgery, irrespective of the technique used.Selected older and ASA III/IIII patients are also eligible for day surgery.

RecommendationsGrade BAn operation in day surgery should be considered for every patient.

(ASA 1 and 2: Always consider day surgery ASA 3/4: consider local anaesthesia, consider day surgery)


What are the recommendations for anaesthesia?

ConclusionLevel 1B• Open anterior inguinal hernia techniques can be satisfactorily performedunder local anaesthetic.• Regional anaesthesia, especially when using high dose / longactingagents has no documented benefits in open inguinal hernia repair andincreases the risk of urinary retention.

RecommendationsGrade A• In case of an open repair, local anaesthetic is considered for all adult patients with a primary reducible unilateral inguinal hernia.Grade B• Use of spinal anaesthesia, especially high dose and/or long actinganaesthetic agents should be avoided.• General anaesthesia with short-acting agents, combined with localinfiltration anaesthesia may be a valid alternative to local anaesthesia.


What are the recommendations for biomaterials?

Level 1A • Operation techniques using mesh result in fewer recurrences thantechniques which do not use mesh.Level 1B• Material-reduced meshes have some advantages with respect to longterm discomfort and foreign body sensation in open hernia repair, but are possibly associated with an increased risk for hernia recurrence (possibly due to inadequate fixation and/or overlap).

RecommendationsGrade A• In inguinal hernia tension-free repair synthetic non-absorbable flat meshes (or composite meshes with non-absorbable component) should be used.• The use of lightweight/material reduced/large-pore (>1000 m) meshes inopen inguinal hernia repair can be considered to decrease longtermdiscomfort but possibly at the cost of increased recurrence rate (possiblydue to inadequate fixation and/or overlap).


Selection of mesh material for TAPP and TEP

Weyhe, D; Schug-Pass C; Klinge U Selection of mesh material for TAPP and TEP.

“In the long-term comparison, light meshes do not lead to verifiable improvements of the quality of life or a reduction of discomfort up to now.

Slight advantages regarding convalescence exist in the first few postoperative weeks.”

Will use of larger mesh prevent recurrence after laparoscopic inguinal hernia repair?

“Small mesh may be a risk factor forrecurrence after laparoscopic inguinal hernia repair (evidence level 2a).

Therefore we recommend use of largemesh, i.e. at least 10x15cm (recommendation level A). In case ofdefects of 5cm or more we suggest using a mesh of at least 12x17cm orSimply 2 meshes with sufficient overlap (evidence level 5, recommendation level D).”

Bisgaaard, T; Rosenberg, J: comments; Mesh size and recurrence

Mesh fixation modalities in endoscopic inguinal hernia repair

• Is it necessary to fixate the mesh in

endoscopic inguinal hernia repair?

• What kind of fixation is to be preferred?

Kuhury, E; Montgomery, A; Fortelny, R Mesh fixation modalities in endoscopic

inguinal hernia repair.

Mesh fixation modalities: statements

Kuhury, E; Montgomery, A; Fortelny, R Mesh fixation modalities in endoscopic inguinal hernia repair.

Grade 1B Mesh fixation and non-fixation are both associated with equally low recurrence rates in both TAPP and TEP.

Non-fixation is associated with a less or similar risk for development of chronic pain compared to fixation.

Fixation of the mesh is more expensive than non-fixation.

The use of fibrin glue was associated with low recurrence rates.

Fibrin glue for mesh fixation is associated with less chronic pain than stapling.

Grade 5 Fibrin glue is less expensive than most stapling devices.

What repair for a faster postoperative recovery?

ConclusionLevel 1A• Endoscopic inguinal hernia techniques result in an earlier return to normal activities or work than the Lichtenstein technique.

RecommendationGrade A• It is recommended that an endoscopic technique is considered if a quick post-operative recovery is particularly important.


ConclusionLevel 3• The imposition of a temporary ban on lifting, participating in sports or working after inguinal hernia surgery, is not necessary. • Probably a limitation in heavy weight lifting for 2-3 weeks is enough.

RecommendationGrade C• It is recommended that limitations are not placed on patients following an inguinal hernia operation and patients are therefore free to resume activities. "Do what you feel you can do". Probably a limitation in heavy weight lifting for 2-3 weeks is enough.


What are the recommendations for postoperative aftercare?

Conclusion

Level 1B• Wound infiltration with a local anaesthetic results in less postoperative pain following inguinal hernia surgery.

RecommendationGrade A• Local infiltration of the wound after hernia repair provides extra paincontrol and limits use of analgesics.


What are the recommendations for postop pain control?

RecommendationsGrade B• In open surgery, operatively evacuate a haematoma which results in tension on the skin.• Wound drains are only used where indicated (much blood loss, coagulopathies).Grade C• Seromas are not aspiratedGrade D• The patient empties his/her bladder prior to endoscopic and open operations.• The fascia transversalis/peritoneum is opened with restrictivity in open surgery of direct hernias. Take care that the bladder might be herniated.• In the case of large hernia sacs, transection of the hernia sac is performed and the distal hernia sac is left undisturbed, so as to prevent ischemic orchitis. Damage to the spermatic cord structures should be avoided.• Patients with previous major lower (open) abdominal intervention or previous radiotherapy of pelvic organs do not undergo endoscopic inguinal hernia surgery.• Due to the risk of intestinal adhesion and bowel obstruction, the extraperitoneal approach (TEP) is used for endoscopic inguinal hernia operations.• Trocar openings of 10 mm or larger are closed.• The first trocar at endoscopic hernia surgery (TAPP) is introduced by the open technique.

European Hernia Society Guidelines: Treatment of Inguinal Hernia in Adult Patients•

What are the recommendations for postop complications?

What are the recommendations for postop complications?

Urinary Retention: The most common predisposing factor for urinaryRetention after hernia repair is the use of regional or general anesthesia.Other factors include age and a history of prostatism (level 1a).

Cord and testicular problems: Testicular complications occur after Both open and endoscopic hernia surgery. No significant differencein the incidence between open and lap in a large comparative trialOr a Cochrane analysis (level 1a Grade A).

Ischemic orchitis is more common after surgery for recurrent herniaOr when complete sac removal is done in scrotal hernia.

Avoid complete transection of cremasteric muscle to prevent testicular descent.

Robert Fitzgibbons Jr. IHES 2009.

ConclusionLevel 1B• From the perspective of the hospital, an open mesh procedure is the mostcost-effective operation in primary unilateral hernias. From a socio-economic perspective an endoscopic procedure is probably the most cost- effective approach for patients who participate in the labour marketespecially for bilateral hernias. In cost-utility analyses including quality oflife (QALY’s) endoscopic techniques (TEP) may be preferable since theycause less numbness and chronic pain.

RecommendationGrade A• It is recommended that, from a hospital perspective, an open mesh procedure is used for the treatment of inguinal hernia. • From a socio-economic perspective an endoscopic procedure is proposed for the active working population especially for bilateral hernias.

European Hernia Society Guidelines: Treatment of Inguinal Hernia in Adult Patients•

What are the recommendations for costs?

How do recurrence rates for open and laparoscopic hernia repair compare?

Reference Year Pts/R Hrns Hernia Tech RR

Bay-Nielson 2001 547 Lap 1.6% 9,982 Licht 1.0%

4,373 Muscle repair 2.7%

EU Hernia 2002 1,643 Lap 2.2%Trialist Collab 1,612 Open 1.7%

Neumayer 2004 862 Lap 10.1%834 Open 4.9%

“Highly experienced” Lap <5%“Less than 250” Lap >10%

No difference in rate of recurrence between laparoscopic and open procedures for primary hernia repair.

What is the role of laparoscopy for treating recurrent inguinal hernia?

• Less recurrence

• Less pain

• Earlier return to activity

• No missed hernia

What percentage of a general surgeon’s practice are recurrent hernias?

• Repair of recurrent hernia is a surrogate for actual recurrence rate.• The reoperation rate is not equal to the true recurrence rate but is a

measure of recurrence serious enough to require reoperation.• The actual incidence of recurrence is higher than stated reoperation

rates by at least 50% (1.7-2.3).

% Hernia Repairs that Present Overall in Population-based Studiesand Large Case SeriesNilsson 1998 (Denmark) 16.0%Felix 1998 (USA) 14.0%Liebl 1999 (Germany) 8.5%Haapaniemi 2001 (Sweden) 15.0%Bay-Nielson 2001 (Denmark) 17.0%Bokeler 2007 (Germany) 14.0%Bisgaard 2008 (Denmark) 3.1%

Consider - you have to be good at repairing recurrent inguinal hernias

Bisgaard 2008 Danish Hernia Database (67,306 primary repairs)–Recurrence rate of primary inguinal hernia repair – 3.1%–Recurrence rate after recurrent inguinal hernia repair – 8.8%

Other studies demonstrate re-recurrence rates as high as 33%

Indeed, specialty centers show low recurrence rates for their

techniques.• Open tension free repair 0% – 8.30% • Laparoscopic TAPP repair 0% – 1.04%

Re-recurrence after TAPP for recurrence (national and large studies)

Reference Year Pts/Hrns PT RT (no. Pts or Hrns) RR (%)

Haapaniemi 2001 NA/2,688 Ant. TAPP, TEP (670) 1.79Licht. (685) 1.46Plug (276) 2.54Other Mesh (574) 3.83Non-mesh (483) 4.35

Bay-Nielson 2001 NA/3,943 Var. TAPP (560) 2.9TEP (78) 1.3Muscle (645) 6.7Licht. (1,697) 3.2Plug (212) 3.8Plug and patch (358) 3.6Other mesh (393) 5.6

Wara 2005 NA/6,689 Unilateral recurrent herniaLicht. Lap. (1,361; 92% TAPP) 4.63

Licht. (4,633) 4.79Bilateral recurrent hernia

Licht. Lap (498; 92% TAPP) 2.61Licht. (172) 7.56

Bokeler 2008 1,689/1,755 Ant. TAPP 0.6

Bisgaard 2008 NA/1,124 Licht. Lap. (388; 95% TAPP) 1.3Licht. (344) 11.3

Non-mesh (198) 19.2Mesh (non-Licht.) (194) 7.2

Pts, patients; Hrns, hernias; PT, primary technique; RT, recurrent technique; RR, recurrence rate; NA, not available; Var., various; TAPP, trans-abdominal pre-peritoneal repair; TEP, totally extra-peritoneal repair; Licht., Lichtenstein repair; Lap, laparoscopy

TEP for recurrent inguinal hernia

Reference Year Pts RT RRR

Bay-Nielson 2001 78 TEP 1.3%

1,697 Licht 3.2%

645 Muscle repair 6.7%

Kouhia 2009 49 TEP 0.0%

Prospective randomized 47 Licht 6.4%

Pts: patients; RT: recurrent technique; RRR: re-recurrence rate;

TEP: totally extra-peritoneal repair; Licht.: Lichtenstein repair

Pain score after TAPP for recurrent inguinal hernia

Reference Year Technique No. of Patients Median VASBeets 1999 TAPP/GPRVS 42/37 2.2/2.9 (p = 0.05)

Mahon 2003 TAPP/Licht. 60/60 2.8/4.3 (p = 0.003)

Dedemadi 2006 TAPP/Licht. 24/32 1.0/2.0 (p = 0.001)

Eklund 2007 TAPP/Licht. 73/74 125 mm/165 mm

(p = 0.019)

Neumayer 2004 Lap./Lich. Difference in VAS

Day of surgery 10.2 mm (favoring TAPP)

Two weeks after surgery 6.1 mm (favoring TAPP)

Three months after surgery No difference

VAS, visual analog of pain score; TAPP, trans-abdominal pre-peritoneal repair; GPRVS, giant

prosthesis for reinforcement of visceral sac; Licht., Lichtenstein repair; Lap, laparoscopy

Pain score after TEP for inguinal hernia

Reference Year Technique No. of Patients Median VAS

Bringman 2003 TEP/Licht/Mesh-plug 92/103/104 1/2/2 (p = 0.001)

Eklund 2007 TEP/Licht 675/706 105/175 (p = 0.001)

Chronic Pain

Kouhia 2009 TEP/Licht 47/49 4/13 (p = 0.02)

VAS: visual analog of pain score; TEP: totally extra-peritoneal repair; Licht: Lichtenstein repairs

Return to regular activity after TAPP for recurrent inguinal hernia

Reference Year Technique Median days to return to work / activity

Beets 1999 TAPP/GPRVS 13/23 (p = 0.03)

Mahon 2003 TAPP/Licht 11/42 (p < 0.001)

Neumayer 2004 Lap./Licht. 4/5 (adj. HR 1.2; 95% CI 1.1 - 1.3)

Dedemadi 2006 TAPP/Licht 14/20 (p = 0.001)

Eklund 2007 TAPP/Licht 8/16 (p = 0.001)

TAPP, trans-abdominal pre-peritoneal repair; GPRVS, giant prosthesis for reinforcement of visceral sac; Licht., Lichtenstein repair; HR, hazard ratio; CI, confidence interval; Lap, laparoscopy

Return to regular activity after TEP inguinal hernia repair

Reference Year Technique Median days to return to work / activity

Bringman 2003 TEP/Licht/Mesh-plug 14/25/29 (p < 0.0001)

Eklund 2007 TEP/Licht 7/12 (p <0.001)

Kouhia 2009 TEP/Licht 15/18 (p = 0.05)

TEP, totally extra-peritoneal repair; Licht., Lichtenstein repair

Management of recurrent inguinal hernias

Kamal MF Itani MD1, Robert Fitzgibbon Jr MD2, Samir S Awad MD3, Quan-Yang Duh MD4, George S. Ferzli MD5

1 Boston VA Health Care System and Boston University, Boston MA2 Creighton University, Omaha NE3 Michael E DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX4 San Francisco VA Medical Center and University of California San Francisco, San Francisco CA5 SUNY Downstate Medical Center and Lutheran Medical Center, Brooklyn NY

1. What is the role of TAPP/TEP after TAPP/TEP?

Questions remaining in 2009

Study Primary Repair Recur. Repair Tech. Re-recurrence Follow upKnook 1999 Various Lap. TAPP 0.0% 35 monthsReview (n = 34)Three institutionsn = 34 patientsn = 34 recurrent herniasTAPP is a reliable technique for repair of recurrent hernia prior endoscopic repair.

Liebl 2000 TAPP (n =44) TAPP 0.0% 26 monthsReview of TEP (n = 2)ProspectiveSingle institution seriesn = 44 patientsn = 46 recurrent hernias

Laparoscopic repair of recurrent inguinal hernia after TAPP can only be done by the transperitoneal approach. It is effective with low complication rates. It requires large mesh. For reoperation, it should be reserved for the experienced endoscopic surgeon.

Kapiris 2001 TAPP (n=17) TAPP (n=16) 0.62% (all repairs) 45 monthsRetrospectiveTwo institutions TAPP (n=16)n = 3,017 patientsn = 3,530 total hernias n = 388 recurrent hernias TAPP is difficult but safe and effective, with high patient satisfaction, in the hands of the well-trained

surgeon.

TAPP/TEP after Recurrence of TAPP/TEP Hernia Repair

Study Primary Repair Recur. Repair Tech. Re-recurrence Follow up

Keider 2002 TAPP / TEP TAPP / TEP 0.0% 37 monthsReview (n = 3)Single institutionn = 3 re-operations by laparoscopy after 7 re-recurrences after laparoscopyLaparoscopic recurrent hernia repair is effective and superior to historical series. It should be the methodof choice if cost could be reduced.

Bittner 2007 TAPP TAPP 0.74% NAReview (n = 135)Single institutionn = 135 recurrent herniasTAPP can be performed for recurrent inguinal hernia after TAPP with low recurrence rate, but the

learning curve is high.

Bisgaard 2008 Laparoscopic TAPP (+/- 95%) (n = 14) 7.1% NAReview of prospective (n = 100) Lichtenstein (n = 73) 2.7%Danish hernia registry Nonmesh (n = 8) 0.0%n = 67,306 primary repairs Mesh (non-Licht.) (n = 5) 0.0%n = 100 recurrent hernias after lap. Laparoscopic repair is recommended for reoperation of a recurrence after primary Lichtenstein repair. Trend favors laparoscopic repair of recurrence after non-mesh and non-Lichtenstein mesh primary repair. Laparoscopic repair of recurrence after laparoscopic primary repair shows no advantage in terms of re-recurrence.

TAPP/TEP after Recurrence of TAPP/TEP Hernia Repair

Recurrence after anterior and posterior repairs

• Laparoscopic posterior repair after posterior repair does not have the benefit of operating in virgin territory and may be best left to those surgeons with extensive laparoscopic experience.

Should the prior mesh be removed or left in place?• Sometimes the old mesh is difficult to remove and bowel and bladder injuries could occur (or the old plug just can’t be cut with scissors). “We left the prior mesh in situ. The dissection starts from the upper edge down behind the mesh, so the mesh remains at the peritoneum. It prevents damage to the peritoneum. Depending on the intra-operative situation we use a second mesh with or without a slit in a double-buttress technique”

Jochen Schwarz, personal correspondence

TAPP after TAPP/TEP

2. Do we have an answer for

groin pain after hernia repair?

Nerves prone to injury at herniorraphy: anterior and posterior

Author # of Pts Pain* Pain Severe Outcome of Pain

A. S. Poobalan 2001 226 30% > 3 mo

Morten Bay-Nielsen 2001 1166 28.7% > year 3%

S. Kumar 2002 454 30% >21 mo

C. A. Courtney 2002 4062 > 3 mo 3% > 2.5 yrs 71% have painSevere in 22% Mild in 45%

Marcello Picchio 2004 593 25% > 1 yr 6%>1 yr

A. M. Grant 2004 928 9.7%>1 yr 1.8% > 5 yrs

Jrg Kninger 2004 208 36% (Shouldice) 31% (Lichtenstein)15% (TAPP)> 52 mo

Ulf Fränneby 2006 2456 31% >24 to 36 mo

Sergio Alfieri 2006 973 9.7% > 6 mo 2.1 %> 6 mo Mild 4.1% > 1yr Severe 0.5% > 1yr

E. K. Aasvang 2006 210 34.3% >1year Less pain 75.8%Same pain 16.7%More severe 7.5%> 6.5 years

* Groin pain or discomfort lasting more than 3 months after groin hernia repair.Intern. Assn. for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain. 1986; 3 (suppl): 1–226.

Groin pain incidence

Quality of life

Author Pts Pain affects the quality of life

Morten Bay-Nielsen 2001 1166 16.6%

S Kumar 2002 454 18.1%

Jrg Kninger 2004 208 14% (Shouldice)

13% (Lichtenstein)

2.4% (TAPP)

Ulf Fränneby 2006 2456 6%

EK Aasvang 2006 210 Nb

24.8%

6% after 6.5 years

Sergio Alfieri 2006 973 11.3% to 14.2%

Causes and risk factors of groin pain

Anatomical Variation Innervation symmetry - 40.6%

Normal distribution - 20.3%

“Normal” anatomic pattern - 56.3%

Mesh repair No clear correlation between use of mesh and chronic pain

Age Studies disagree on correlation between older age and post-herniorrhaphy pain

Pre-operative pain Pain associated with hernia before repair is associated with post-operative pain

BMI No correlation found between elevated BMI and post-operative pain

Post-operative complications

Postoperative complications linked to an increased risk for long term pain

Recurrent hernia

Day case surgery

Open versus laparoscopic

Recurrence associated with recurrent pain

The probability of developing chronic pain is 2.5 times higher in day-case patients, controlling for age

Open repair strongly correlated with post-operative pain compared to laparoscopic repair

What are the recommendations for chronic pain?

Conclusions; causes and risk factors.Level 1B• The risk of chronic pain after hernia repair with mesh is less than after nonmesh repair.• The risk of chronic pain after endoscopic hernia repair is lower than afteropen hernia repair.

Level 2A• The overall incidence of moderate to severe chronic pain after hernia surgery is around 10-12 %.• The risk of chronic pain after hernia surgery decreases with age.

Level 2B• Preoperative pain may increase the risk of developing chronic pain after hernia surgery.• Preoperative chronic pain conditions correlate with the development of chronic pain after hernia surgery.• Severe early postoperative pain after hernia surgery is correlated to the development of chronic pain.• Females have an increased risk of developing chronic pain after hernia surgery.


What are recommendations for prevention of chronic pain?

ConclusionsLevel 1B• Material reduced meshes have some advantages with respect to longterm discomfort and foreign body sensation in open hernia repair (when only considering chronic pain).Level 2A• Prophylactic resection of the ilioinguinal nerve does not reduce the risk of chronic pain after hernia surgery.Level 2B• Identification of all inguinal nerves during open hernia surgery may reduce the risk of nerve damage and postoperative chronic groin pain.

Treatment of chronic painLevel 3• A multidisciplinary approach at a pain clinic is an option for the treatment of chronic post herniorrhaphy pain.• Surgical treatment of specific causes of chronic post herniorrhapy pain can be beneficial, such as resection of entrapped nerves, mesh removal in mesh-related pain, removal of endoscopic staples or fixating sutures.


3. What is the role of laparoscopy in the complex inguinal hernia?

• Scrotal hernia

• Incarcerated

• Strangulated hernia: in the setting of peritonitis and bowel necrosis

What are the recommendations for laparoscopic management of complex hernias?

Complex Hernia Type

Management Recommendations Level of Evidence(Authors)

Scrotal •TAPP and TEP can be used with good results•Reserved for highly experienced TAPP/TEP surgeons

III(Ferzli, Liebl, Palanivelu)

Incarcerated Inguinal

•TAPP may be used for acute or chronic incarceration•TAPP allows easy inspection of questionable bowel

•TEP may be used for acute or chronic incarceration•Must convert to intra-abdominal port to inspect bowel

•Reserved for highly experienced TAPP/TEP surgeons

IV(Palanivelu, Leibl,

Rebuffat, Ishihara,Legnani,

Scierski)III

(Ferzli, Tamme, Saggar)

Strangulated Hernia with Peritonitis

•Laparoscopic (TAPP or TEP) repair of strangulated hernia should be avoided in the setting of :Frank peritonitis Infected abdominal wall Necrotic bowel

IV(Liebl, Ishihara, Ferzli)

Can we reduce mortality?

RecommendationsGrade B• Offer patients with femoral hernia early planned surgery, even if symptoms are vague or absent.

Grade D• Intensify efforts to improve early diagnosis and treatment of patients with incarcerated and or strangulated hernia.


Bernhardt GA et al. World J Surg (2009) 33:2050-2055

Survey: 2441 Hernia Repairs in 2007

• 19.9 percent tissue repair!!

• 36 percent Lap repair.

• 7 percent Lap in the US, 26.9 percent in Germany.

• Surgeons follow the “Departmental Policy”.

• The Chief (Chefarzt) is always right.

• Surgeons do not follow “evidence” but “eminence”.

Holzheimer, RG Inguinal Hernia Repair: What to do with the evidence? World J Surg (2009) 33: 2056-2057

Conclusion

Conclusions:

• Laparoscopic inguinal hernia repair in 2009 is feasible for primary, bilateral and recurrent hernias.

• The main challenge remains the learning curve.

• A thorough knowledge of the anatomy is of utmost importance.

Mesh fixation modalities: recommendations

Kuhury, E; Montgomery, A; Fortelny, R Mesh fixation modalities in endoscopic inguinal hernia repair.

Level B

In case of endoscopic inguinal hernia repair by TAPP technique, non-fixation of the mesh could be considered in type L I hernia (EHS classification).

In case of endoscopic inguinal hernia repair by TEP technique, non-fixation of the mesh could be considered in type L I, II and M hernia (EHS classification).

In case of recommended fixation, a fibrin glue mesh fixation in endoscopic repair of inguinal hernia should be considered with regard to minimize the risk of postoperative chronic pain.

laparoscopic inguinal hernia repair eminence-based or evidence-based?

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