Laparoscopic inguinal Laparoscopic inguinal herniorrhaphyherniorrhaphy

PROS AND CONSPROS AND CONS

George Ferzli MD, FACSGeorge Ferzli MD, FACSProfessor of SurgeryProfessor of Surgery

SUNY DownstateSUNY Downstate

Where is the controversy?Where is the controversy?

Only open hernias can be done Only open hernias can be done with spinal or local anesthesiawith spinal or local anesthesia

But then:But then:

But then:But then:

Recurrent hernias cannot be Recurrent hernias cannot be repaired via laparoscopyrepaired via laparoscopy

Laparoscopic preperitoneal repair of recurrent inguinal hernias

P. Sayad, G Ferzli

J Laparoendosc Adv Surg Tech A 9:127-130 (1999)

But then:But then:

Surg Endosc 13:822-823 (1999) © 1999 by Springer-Verlag New York, Inc.

Needlescopic extraperitoneal repair of inguinal hernias

G. Ferzli, P. Sayad, J. Nabagiez

Then the instruments became Then the instruments became smallersmaller

Scrotal hernias cannot be repairedScrotal hernias cannot be repairedlaparoscopicallylaparoscopically

But then:But then:

Another advantage of Another advantage of laparoscopy:laparoscopy:

Recurrences after a laparoscopic Recurrences after a laparoscopic inguinal hernia repair must be done inguinal hernia repair must be done

via an open approachvia an open approach

But then:But then:

What do the prospective What do the prospective randomized studies show?randomized studies show?

Author/YearAuthor/Year N=HerniasN=Hernias TAPP vs. TEPTAPP vs. TEP ComplicationsComplications

Felix/1998Felix/1998 1005310053 TAPP 5163TAPP 5163

TEP 4890TEP 4890

Recurrence 0.4%Recurrence 0.4%

Bittner/2002Bittner/2002 80508050 TAPPTAPP Recurrence 0.7%Recurrence 0.7%

Conversion 0.1%Conversion 0.1%

Bleeding 0.5%Bleeding 0.5%

Mesh infection 0.1%Mesh infection 0.1%

Trocar site hernia 0.7%Trocar site hernia 0.7%

Nerve injury 0.3%Nerve injury 0.3%

Bladder injury 0.1%Bladder injury 0.1%

Bowel injury 0.1%Bowel injury 0.1%

Ferzli/2002Ferzli/2002 11821182 TEPTEP Mesh infection 0.08%Mesh infection 0.08%

Bladder injury 0.1%Bladder injury 0.1%

Bowel injury 0.1%Bowel injury 0.1%

Neuralgia 0.1%Neuralgia 0.1%

Tamme/2003Tamme/2003 52035203 TEPTEP Mesh infection 0.02%Mesh infection 0.02%

Hematoma 1.8%Hematoma 1.8%

Neuralagia 0.3%Neuralagia 0.3%

Throughout the evolution of Throughout the evolution of laparoscopic hernia repair certain laparoscopic hernia repair certain outcome measuresoutcome measures have been have been evaluated to validate the procedureevaluated to validate the procedureRecurrence rateRecurrence rate

ComplicationsComplications

Operative timeOperative time

Postoperative painPostoperative pain

Return to workReturn to work

CostCost

ReproducibilityReproducibility

……We reviewed…We reviewed…

All Prospective Randomized studies All Prospective Randomized studies comparing open to laparoscopic hernia comparing open to laparoscopic hernia repairrepair

38 studies from 1990 to 200038 studies from 1990 to 2000

Recurrence Rate*

*

*

0.30

0.25

0.20

0.15

0.10

0.05

0.00

0.05

0.10

0.15

0.20A

itola

199

8

Bee

ts 1

999

Cha

mpa

ult 1

997

Dirk

sen

1998

Fili

pi 1

996

Hau

ters

199

6

Joha

nsso

n 19

99

Juul

199

9

Kal

d 19

97

Kho

ury

1998

Kon

inge

r 19

98

Law

renc

e 19

95

Lie

m 1

997

Mad

dem

199

4

Pag

anin

i 199

8

Pay

ne 1

996

Sch

renk

199

6

Tan

phip

hat 1

998

Tsc

hudi

199

6

Rec

urr

ence

Rat

e (p

erce

nt)

Laparoscopy

Open

Difference

Laparoscopic RecurrencesLaparoscopic Recurrences

Mesh too smallMesh too small

Use of incised meshUse of incised mesh

Inadequate dissection and missed cord Inadequate dissection and missed cord lipomalipoma

Displacement of meshDisplacement of mesh

Leibl. J Am Coll Surg. 2000;190:651

Recurrence RateRecurrence Rate

Most recurrences are technical failures.Most recurrences are technical failures.

Recurrences are more common during the Recurrences are more common during the learning phase of laparoscopic repair.learning phase of laparoscopic repair.

In experienced centers, recurrence rates In experienced centers, recurrence rates equal or fall below those of open repair equal or fall below those of open repair techniques.techniques.

Complications

**

*

*

*

1.20

1.00

0.80

0.60

0.40

0.20

0.00

0.20

0.40

0.60

0.80B

arku

n 19

95

Bee

ts 1

999

Bes

sell

1996

Cha

mpa

ult 1

997

Hei

kkin

en 1

997

Joha

nsso

n 19

99

Juul

199

9

Kal

d 19

97

Law

renc

e 19

95

Lor

enz

2000

Mad

dem

199

4

Mill

ikan

199

4

O'D

wye

r 19

99

Pay

ne 1

994

Pic

chio

199

9

Sto

ker

1994

Tan

phip

hat 1

998

Tsc

hudi

199

6

Wel

lwoo

d 19

98

Wrig

ht 1

996

Zie

ren

1998

Com

plic

atio

n R

ate

(per

cent

)

Laparoscopy

Open

Difference

ComplicationsComplications

Complications occur that are unique to Complications occur that are unique to laparoscopic repair (e.g. trocar injuries).laparoscopic repair (e.g. trocar injuries).Laparoscopic complications tend to be more Laparoscopic complications tend to be more serious than open (e.g. vascular and bowel serious than open (e.g. vascular and bowel injuries).injuries).Complication rates are higher during the learning Complication rates are higher during the learning phase of laparoscopic repair.phase of laparoscopic repair.In experienced centers, complication rates equal In experienced centers, complication rates equal or fall below those of open repair techniques.or fall below those of open repair techniques.

Operative Time

* ***

**

*

*

150.00

100.00

50.00

0.00

50.00

100.00

150.00

Aito

la 1

998

Bee

ts 1

999

Cha

mpa

ult 1

994

Cha

mpa

ult 1

997

Dam

amm

e 19

98

Dirk

sen

1998

Filip

i 199

6

Hau

ters

199

6

Hei

kkin

en 1

997

Joha

nsso

n 19

99

Juul

199

9

Kal

d 19

97

Kho

ury

1998

Kon

inge

r 199

8

Koz

ol 1

997

Law

renc

e 19

95

Leib

l 199

5

Liem

199

7

Mad

dem

199

4

Paga

nini

199

8

Payn

e 19

94

Sarli

199

7

Schr

enk

1996

Tan

phip

hat 1

998

Tsc

hudi

199

6

Zie

ren

1998

Du

rati

on (

min

ute

s)

Laparoscopy

Open

Difference

Operative TimeOperative Time

All comparative series show longer operative All comparative series show longer operative times for laparoscopic repair.times for laparoscopic repair.Operative time is longer during the learning Operative time is longer during the learning phase of laparoscopic repair.phase of laparoscopic repair.Laparoscopic bilateral repairs have been Laparoscopic bilateral repairs have been shown to be shorter than open.shown to be shorter than open.In experienced centers, the duration of In experienced centers, the duration of laparoscopic repair laparoscopic repair at bestat best is shown to be is shown to be statistically similar to open repair.statistically similar to open repair.

Postoperative Pain

* *

*

**

**

*

*

15.00

10.00

5.00

0.00

5.00

10.00

Bar

kun

1995

Bee

ts 1

999

Bes

sell

1996

Fili

pi 1

996

Hei

kkin

en 1

997

Hei

kkin

en 1

998

Joha

nsso

n 19

99

Koz

ol 1

997

Law

renc

e 19

95

Lor

enz

2000

Mad

dem

199

4

Pay

ne 1

994

Pic

chio

199

9

Sch

renk

199

6

Sto

ker

1994

Tan

phip

hat 1

998

Tsc

hudi

199

6

Wel

lwoo

d 19

98

Wrig

ht 1

996

Zie

ren

1998

Pai

n S

core

Laparoscopy

Open

Difference

Postoperative PainPostoperative Pain

Is assessed differently from study to study.Is assessed differently from study to study.– Pain scoring scalesPain scoring scales– Tracking analgesic administrationTracking analgesic administration– Measuring post operative exercise toleranceMeasuring post operative exercise tolerance

Most comparative series show a significant Most comparative series show a significant benefit in the laparoscopic repair groups.benefit in the laparoscopic repair groups.

Return to Work

*

*

*

*

*

***

*50.00

40.00

30.00

20.00

10.00

0.00

10.00

20.00

30.00

40.00

Aito

la 1

998

Bee

ts 1

999

Cha

mpa

ult 1

997

Dam

amm

e 19

98

Hau

ters

199

6

Hei

kkin

en 1

997

Joha

nsso

n 19

99

Juul

199

9

Kho

ury

1998

Kon

inge

r 19

98

Law

renc

e 19

95

Lei

bl 1

995

Lie

m 1

997

Mad

dem

199

4

Mer

ello

199

7

Nat

hans

on 1

996

Pag

anin

i 199

8

Sar

li 19

97

Sch

renk

199

6

Sto

ker

1994

Tan

phip

hat 1

998

Zie

ren

1998

Day

s to

Ret

urn

to

Wor

k

Laparoscopy

Open

Difference

Return to WorkReturn to Work

Time off work seems to be related to the Time off work seems to be related to the type of type of – hernia (unilateral vs bilateral : primary vs hernia (unilateral vs bilateral : primary vs

recurrent)recurrent)– repair techniquerepair technique– occupationoccupation

Most comparative series show a significant Most comparative series show a significant benefit in the laparoscopic groups.benefit in the laparoscopic groups.

Cost

* *

*

8,000.00

6,000.00

4,000.00

2,000.00

0.00

2,000.00

4,000.00

6,000.00

8,000.00

10,000.00

12,000.00

Bar

kun

1995

Far

inas

200

0

Hei

kkin

en 1

997

Hei

kkin

en 1

998

Joha

nsso

n 19

99

Kal

d 19

97

Law

renc

e 19

95

Lie

m 1

997

Lor

enz

2000

Mill

ikan

199

4

O'D

wye

r 19

99

Pay

ne 1

994

Sto

ker

1994

Wel

lwoo

d 19

98

Zie

ren

1998

Cos

t (D

olla

rs)

Laparoscopy

Open

Difference

Item Necessary Unnecessary ReducibleAnesthetic agents X XInpatient pain medication X XOutpatient pain medication XAnesthesia XDrapes XSuction-irrigation tubes XDisposible trocars XBalloon dissector XMesh X XEndoscopic stapler XFascial closure suture X XSkin suture XDressings XFoley catheter XRecovery room charge XOperating room Charge X X

Swanstrom. Surg Clin N Am. 2000;80:1341

Cost Reduction

0

1000

2000

3000

4000

5000

6000

7000

1995 1996 1997 1998

Year

Hos

pita

l Cha

rges

(do

llars

)

Laparoscopic

Open

Swanstrom. Surg Clin N Am. 2000;80:1341

CostCost

If only material and equipment costs are If only material and equipment costs are evaluated, laparoscopic repair is more evaluated, laparoscopic repair is more expensive.expensive.If time off work is considered, laparoscopic If time off work is considered, laparoscopic repair can be shown to be modestly cheaper repair can be shown to be modestly cheaper than open repair. than open repair. Significant reductions in the cost of Significant reductions in the cost of laparoscopic repair can be achieved by laparoscopic repair can be achieved by eliminating unnecessary and disposable eliminating unnecessary and disposable equipment.equipment.

Outcome MeasuresOutcome MeasuresDuring thelearning curve

Beyond thelearning curve

Recurrence rate Higher Equal

Complication rate Higher Equal or lower

Operative time Longer Equal or longer

Postoperative pain Less Less

Return to work Quicker Quicker

Cost Greater Equal or lower

Reproducibility ????? ?????

……We reviewed…We reviewed…

All studies regarding the learning curve All studies regarding the learning curve

16 studies from 1989 to 199916 studies from 1989 to 1999

Only 3 studies attempted quantitative Only 3 studies attempted quantitative analysis, suggesting 30-50 cases to analysis, suggesting 30-50 cases to achieve technical proficiencyachieve technical proficiency

……but where is the greatest but where is the greatest impact of the learning impact of the learning curve?curve?

……We reviewed…We reviewed…

Surgical resident and chief resident Surgical resident and chief resident operative experience in laparoscopic operative experience in laparoscopic cholecystectomy and herniorrhaphy over cholecystectomy and herniorrhaphy over a 10-year perioda 10-year period

ACGME General surgery database from ACGME General surgery database from 1989 to 19991989 to 1999

Resident Experience in Resident Experience in CholecystectomyCholecystectomy

During 5 year residency During chief year Year

Total open Total lap Average open

Average lap

Total open Total lap Average open

Average lap

1988-1989 54861 54.4 12459 12.3 1989-1990 55920 57.1 12452 12.7 1990-1991 59895 59.0 13298 13 1991-1992 60785 60.2 17647 17.5 1993-1994 35412 41984 35.4 42.0 7389 19498 7.4 19.5 1994-1995 29953 52265 30.0 52.0 6778 21397 6.8 21.4 1995-1996 25787 60175 25.8 60.2 6378 20710 6.4 20.7 1996-1997 21971 70345 21.6 69.2 5902 21888 5.8 21.5 1997-1998 18640 73172 18.8 73.7 5282 21956 5.3 22.2 1998-1999 16835 80247 16.7 79.5 4371 20710 12.3 28.9

Resident Experience inResident Experience inHernia RepairHernia Repair

During 5 year residency During chief yearYear

Totalopen

Total lap Averageopen

Averagelap

Totalopen

Total lap Averageopen

Averagelap

1988-1989 51576 51.1 7889 7.81989-1990 51732 52.8 8053 8.21990-1991 54657 53.8 8067 7.91991-1992 55187 54.7 8468 8.41993-1994 53295 2895 53.3 2.9 7915 1790 7.9 1.81994-1995 52563 3637 52.6 3.6 7558 1906 7.6 1.91995-1996 52262 4665 52.3 4.7 7503 2178 7.5 2.21996-1997 54182 5672 53.3 5.6 8253 2496 8.1 2.51997-1998 38589 16875 38.9 17.0 7711 2678 7.8 2.71998-1999 52354 6940 51.8 6.9 6975 2636 6.9 2.6

Total Resident Cases

0

20,000

40,000

60,000

80,000

100,000

120,000

1988-1989 1989-1990 1990-1991 1991-1992 1993-1994 1994-1995 1995-1996 1996-1997 1997-1998 1998-1999

Year

Tot

al N

um

ber

of

Cas

es

open chole

lap chole

open hernia

lap hernia

total chole

total hernia

Average Case per Resident

0

10

20

30

40

50

60

70

80

90

1988-1989 1989-1990 1990-1991 1991-1992 1993-1994 1994-1995 1995-1996 1996-1997 1997-1998 1998-1999

Year

Ave

rage

Num

ber

of C

ases

open chole

lap chole

open hernia

lap hernia

Average Case per Chief Resident

0

5

10

15

20

25

30

35

1988-1989 1989-1990 1990-1991 1991-1992 1993-1994 1994-1995 1995-1996 1996-1997 1997-1998 1998-1999

Year

Ave

rage

Num

ber

of C

ases

open chole

lap chole

open hernia

lap hernia

Given the data regarding Given the data regarding training experience, we can training experience, we can only conclude that our only conclude that our graduating residents are not graduating residents are not beyond the learning curve.beyond the learning curve.

In order for lap inguinal hernia In order for lap inguinal hernia results to be equal to open results to be equal to open hernia, surgeons must be hernia, surgeons must be

beyond their own learning curvebeyond their own learning curve