laparoscopic vs open inguinal hernia repair

Slide 1

Andrew S. Wright MD

Director, UW Medicine Hernia Center

Twitter: @andrewswrightEmail: [email protected]

Open vs. MIS Inguinal Hernia

Types of hernia repairOpen TissueHigh LigationBassiniMcVayHalsteadShouldiceDesardaMarcyOpen Anterior RepairLichtensteinModified LichtensteinOpen Posterior RepairPlugOnStepStoppaOpen Hybrid repairPlug/patchPHS/UHSLap RepairTEPTAPPrTAPPeTEPIPOM


Lichtenstein Repair is Gold Standard

Not all hernias are the same!

Not all hernias are the same!

Hernia Outcomes that Matter

Hernia Outcomes that MatterRecurrence2-5%Highly dependent on Surgeon experience and volume

Outcomes that matter - PainChronic Pain8-20% Mesh sensation1-2% Daily pain0.1% Disabling

Outcomes that matter - PainChronic Pain8-20% Mesh sensation1-2% Daily pain0.1% Disabling770,000 hernia repairs annually

Outcomes that matter - PainChronic Pain8-20% Mesh sensation1-2% Daily pain0.1% Disabling770,000 hernia repairs annually77,000 patients with disabling pain

Outcomes that matter - Pain

Secondary OutcomesCostOR timeReturn to workCosmesis

Option: Watchful WaitingAcute event 1.8/1,000 patient yearsNo limitation on exercise or activity

Option: Watchful WaitingAcute event 1.8/1,000 patient yearsNo limitation on exercise or activity

Crossover 76% at 7 years

Tissue Repair: why?20% Google searches for health information



Option 1: Tissue RepairShouldice

ShouldiceHighly selected patientTechnical and operator dependent

ShouldiceCochrane review 2012 Shouldice vs. other open tissue repairs

Open Mesh (Lichtenstein) RepairAdvantagesQuickReproducibleLocal anestheticLow recurrenceDisadvantagesForeign BodyProximity to nerves

ShouldiceCochrane review 2012 Shouldice vs. mesh repairs

24

ShouldiceCochrane review 2012 Shouldice vs. mesh repairs

No decrease in chronic pain in Shouldice vs. Lichtenstein


Lichtenstein Repair is Gold Standard

LichtensteinKey step!Identification and preservation of nerves

LichtensteinKey step!Identification and preservation of nerves

1/3 Reduction in pain at 3 months with intra-op Marcaine nerve block

Lichtenstein modificationsno-suture glue technique (TIMELI trial)Significant reduction in disabling painNo difference in recurrence

ProGrip

ProGrip mesh

ProgripPotential benefitsReduced risk of nerve injuryFaster OR timePotential disadvantagesIncreased costIncreased inflammatory reactionSeveral single center RCTs UnderpoweredNo difference in chronic pain or recurrencePossible increase in foreign body sensation

Options: Open Preperitoneal GroinMesh PlugPHS Prolene Hernia SystemUHSONSTEPInsightraKugelTREPP (transrectus preperitoneal)

Outcomes of open preperitoneal repairMost proprietary systems lacking data3 year outcomes no different than standard Lichtenstein

My RecsOpen preperitoneal repairs burn bridgesPlug migrationMeshomaNo evidence that any proprietary system better than Lichtenstein

Option: Open Preperitoneal (Midline)Stoppa Repair Maximally invasive

Stoppa Repair

MIS Inguinal Hernia Repair

Laparoscopic RepairAdvantagesLess short term and chronic pain, Faster RecoveryAddress bilateral hernias, femoral herniasAvoid ilioinguinal and iliohypogastric nerves

Laparoscopic RepairDisadvantagesTechnically more challengingBetter outcomes in RCTs and in expert hands

Lap vs Open: What Does the Data Say?Neumayer L et al. NEJM 2004: 350(18); 1819-1827.Multicenter randomized trial, VA1983 patientsTwo year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%

Lap vs Open: What Does the Data Say?Neumayer L et al. NEJM 2004: 350(18); 1819-1827.Multicenter randomized trial, VA1983 patientsTwo year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%Concluded: primary unilateral hernias should be repaired with OIHR

Lap vs Open: What Does the Data Say?Neumayer L et al. NEJM 2004: 350(18); 1819-1827.Multicenter randomized trial, VA1983 patientsTwo year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%Concluded: primary unilateral hernias should be repaired with OIHRCritique:Average age of pts was high, health related QOL low c/w general populationVA PopulationSurgeon inexperience/learning curveThose with >250 cases had recurrence rate

laparoscopic vs open inguinal hernia repair

Health & Medicine