vin open hernia debate asimanicon 2015

Open / Laparoscopic Groin Hernia Surgery

Dr. Vinay H DDept. of Surgery,RIMS, Imphal

Hi, Hands up for Open Hernia Surgery……….

11th OCT, ASIMANICON 2015

Disclosures

No Disclosures

Why is this a hot topic ?

Surgical repair of inguinal hernias is a common procedure.

However, recurrence of hernias has been reported to occur after repair in 15 % or more cases, and postoperative pain and diability are frequent.

But the most effective surgical technique is unknown.

What’s the burden ?• Abdominal wall hernias are common(occur in at least 2% of

men1)

• USA 15 per 1000 population (1.5%).2

• >20 million hernias are repaired every year around the world.3

• Per year 800,000 hernia repairs are carried out in the USA,4 and over 100,000 in the UK.

Inguinal Hernia - epidemiology

• Very Common• Life Time Risk: % : 27 M :3 F • >20million Repairs/yr/worldwide• 100-300 / 100000 / yr• 100,000 in UK /yr• 800,000 in US• Approx > ?? in India /yr

1. Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835-9.2. Kingsnorth AN, LeBlanc KA. Management of abdominal hernias. 3rd ed.London, New York: Edward Arnold, 2003:40-7.3.Samir S A, Shawn P F .Current Approach to Inguinal Hernia Repair. Am J Surg 2004;188-6;9-164. Richard Burnley: http://online.epocrates.com/u/2942723/inguinal+hernia 2012 Dec: BMJ Content

Are there complications ?In general, patients with uncomplicated inguinal and abdominal

wall hernias do well.

Hernia can lead

• incarcerated and often obstructed bowel• strangulated bowel,• can result in bowel perforation and peritonitis.

• Mortality is 10% for those who have hernias with associated strangulation.


Inguinal Hernia Repairoptions a complex choice

• Open primary suture repairShouldice, Bassins

• Openmesh RepairLichtenstein, Kugal, PHS, Plug/Patch

• Laparoscopic RepairTEP, TAPP, IPOM

Lichtenstein• Open incision

• Mesh placed anteriorly

• Adequate fixation

• Gold Standard by which tension free repairs are measured

kugel

• Open / laparoscopic• Limited visualization• Mesh (heavy weight polypropylene) may migrate and

shrink

Plug and Patch• Open incision

• Limited mesh coverage

• Fixation varies

• Plug (heavy weight polypropylene) may migrate and contract

• May lead to increased chronic pain

Prolene Hernia System• Open incision

• Mesh coverage preperitoneal and anterior to defect

• Heavy weight polypropylene

• Some learning curve (knowledge of preperitoneal anatomy similar to the Kugel & laparoscopic approaches)


Primary Suture Repair

• Open incision

• Repair under tension

• Recurrence can occur over time

• Has decreased in popularity (not dead yet)


Ideal method of hernia repair

• Minimal discomfort both during the surgery & post op.

• Technically simple to perform & easy to learn

• Low rate of complication & recurrence

• Require only a short period of convalescence

• Finally cost effective is important.


Lichtenstein Open Hernia Surgery

• Suitable for all adults, irrespective of age, weight, general health, medical problems.

• Time tested procedure

• Can be done under local anaesthesia

• Considered as Criterion Standard, Gold Standard by which tension free repairs are measured


Lichtenstein Open Hernia SurgeryPreferred:• Large Scrotal (irreducible) Hernia

• Major Lower Abdominal Surgery

• No General Anaesthesia – C/I

• Learning curve 5 cases

• Time tested safe & economical• Low operation time• Low complication• Gold standard

Laparoscopic Hernia Surgery

“Laparoscopy is only an approach, not a procedure”

Laparoscopic complications:

Disastrous like– Laparoscopic injuries– Bowel obstruction

Effect of GA/ Pneumo-peritoneum/ ACS/ Cardio Pulmonary effects, Retention

More Expensive


It is not Minimally Invasive Surgery,

Its Minimally Access Surgery

only.


Laparoscopic Hernia Surgery

• Learning curve (200-300 cases)

• Long term recurrence are lacking.

• Longer operation time.

• C/I in strangulated hernia, sliding hernia,irreducible hernia & patients who are elderly or have co-morbid conditions.

• Laparoscopic hernia repair can be not beperformed as day care surgery or under local anesthesia


To Conclude• Open Mesh Repair is economical, easy to teach & learn

without any steep learning curve.

• Doesn’t need any specialized training.• Results same in all centers.

• Does not carry any risk of serious visceral or bowel injuries.

• Is suitable for all types of groin hernias including strangulated, irreducible, sliding hernia or elderly patients and patients with co-morbidity.

• Is ideal for day-care surgery, especially under local anesthesia.


To Conclude• Laparoscopic Hernia Repair is more costly; difficult to learn,

steep learning curve.

• Risk of serious visceral and or vascular injuries.

• All cases of groin hernia are not suitable for laparoscopic hernia repair as it is contraindicated in strangulated, sliding, irreducible and patients who are elderly or have co-morbid conditions.

• Laparoscopic hernia repair can be not beperformed as day care surgery or under local anesthesia.

Lets contact: [email protected]

Thank You

No disease of the human body, belonging to the province of the surgeon, requires in its treatment a greater combination of accurate

anatomical knowledge with surgical skill than hernia in all it’s varieties.

vin open hernia debate asimanicon 2015

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