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What’s New in Hernia Surgery

What’s New in Hernia Surgery. Centro Cristao de Chicuque, Mozambique June 20, 2009 William A Liston MD Assistant Professor of Surgery Uniformed Services University of the Health Sciences Bethesda MD USA. Disclosures.

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What’s New in Hernia Surgery

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  1. What’s New in Hernia Surgery Centro Cristao de Chicuque, Mozambique June 20, 2009 William A Liston MD Assistant Professor of Surgery Uniformed Services University of the Health Sciences Bethesda MD USA

  2. Disclosures • I have no financial interest in any of the products mentioned in this talk. • I have no research sponsored by any of companies that manufacture any of the products featured. • My only source of income comes from my salary from the US Navy.

  3. Many treatments have been tried since ancient times to cure hernias – most were unsuccessful.

  4. Topics for Discussion • Inguinal Hernia • Wait for symptoms, open repair, laparoscopic repair • Umbilical Hernia • Mesh versus sutures • Open versus laparoscopic • Incisional/ Ventral Hernia • Open versus laparoscopic • What kind of mesh • Component separation techniques

  5. Inguinal Hernia Repair History of surgery for hernia goes back to reports from ancient Egypt 1600 BC Modern repairs date back to Bassini in Padua, Italy in 1887 and Marcy in Boston, 1887 (presented in London) Tissue repairs dominated until the mid 1980’s McVay, Bassini, Shouldice, Marcy Plug/ Plug and patch mesh repairs in early 1980’s Lichtenstein, Gilbert, Stoppa, Kugel

  6. Inguinal Hernia Repair (continued) • Laparoscopic Repair began in early 1990’s • TEP (total extraperitoneal ) with various types of mesh • TAPP (transabdominal preperitoneal) • Various course offered to teach techniques • Driven by the medical industry and patient demand as Laparoscopic Cholecystectomy was in the US

  7. Choices for the Patient • Repair or wait – Fitzgibbons JAMA 2006 • Asymptomatic patients • Complications of hernia repair – groin pain • Risk of complications from waiting – incarceration • No real difference in results • Laparoscopic versus open repair • Neumayer NEJM 2004 favored open repair except for bilateral and recurrent hernias

  8. Open Repair – Tissue • Bassini • Easy to learn, recurrence rate high • McVay • More difficult to learn but recurrence rate lower, patients have more pain postoperatively • Shouldice • Somewhat easy to learn, recurrence rate low in expert hands, less painful postoperatively • All have advantage of no foreign body and low expense but relatively high recurrence rate

  9. Bassini Repair

  10. Shouldice Repair

  11. McVay Repair

  12. Open Repair - Mesh • Lichtenstein, Stoppa, Kugel, Gilbert • Easy to learn • Relatively inexpensive • Low recurrence rates • May use any type of anesthesia • Disadvantages include placing a foreign body in tissue and possible ilioinginal nerve entrapment • Long track record for successful repair

  13. Lichtenstein Repair

  14. Kugel Patch Kit

  15. Complications • Mesh infections • Nerve entrapment • Chronic groin pain • Source of income for attorneys to sue surgeons because of the “evil mesh”

  16. Laparoscopic Repair - Advantages • Earlier return to work • Low recurrence rate? • With TAPP you have diagnostic laparoscopy • Bilateral hernia repair may be performed at one operation • Postoperative pain less?

  17. Laparoscopic Repair - Disadvantages • Requires general anesthesia • Much expensive • More difficult to learn for surgeons • Recurrence rates higher? • Chance for intra-abdominal injuries

  18. LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR Br J Surg 2000 OPEN LAP p<0.001 p<0.001 Operative time Length of stay Postoperative pain Return to work Complications Recurrence - x x - 2.3% x - - 2.9% x Indicates more favorable outcome

  19. LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR Br J Surg 2000 OPEN LAP Complications Hematoma Infection Testicular injury Seroma Visceral or vascular injury x x x x x * Indicates more favorable outcome

  20. Laparoscopic Repair • TEP versus TAPP • TEP • Anatomy and repair more difficult to learn • Stay out of peritoneum • Easier to do direct and bilateral repairs • TAPP • Diagnostic laparoscopy, anatomy easier to see • Indirect repairs easier • Have to close peritoneum over mesh and bowel injury possible

  21. TEP • Totally Extra-Peritoneal (TEP)

  22. TAPP • Trans Abdominal Preperitoneal (TAPP)

  23. Nerves Epigastrics Anatomy Direct Hernia Indirect Hernia Ileopubic tract Femoral Hernia Vas Obturator hernia Iliacs

  24. Umbilical Hernia Repair • Reports of high recurrence rates with defect greater than 3 cm using suture repair only • Laparoscopic versus open repair using mesh • Gonzalez JSLS 2003 • Placement and type of mesh • Ventralex

  25. Ventralex Mesh Patch

  26. Incisional/ Ventral Hernia Repair • Open versus Laparoscopic with or without Component Separation • Postoperative pain, return to work, cost • Open repair • Suture versus mesh repair • Placement of mesh and what type • Mesh types • Polypropylene – Marlex • Double sided – Dualmesh • Biologic – Alloderm, Strattice

  27. Dualmesh Sheet

  28. Case using a combination of techniques • 25 y/o wounded marine in Iraq with multiple abdominal and extremity injuries which required many abdominal surgeries and leaving the abdominal wound open for 3 weeks • Abdominal fascia closed initially with “alloderm” and then skin was closed over in about a week • Patient developed a large incisional hernia • Component separation hernia was scheduled for about 11 months after his original injury

  29. Operative Description • The skin scar was removed and the alloderm attached to the anterior fascia was removed • The fascia was excised to good edges and a large fascial defect remained • The rectus sheath was incised in the top and bottom layers medially to gain more “stretch” to move the edges of the fascia together • A large defect remained

  30. Laparoscopic portion • Trocars were placed in the lateral aspect of the rectus sheath extraperitoneally and a 30 degree laparoscope was inserted and the lateral posterior rectus sheath was divided throughout the length • This gained about another 4 to 5 cm of closing the fascia

  31. Closing techniques • Vicryl mesh (absorbable) was used to closed the most posterior layer • Prolene mesh was used above that layer • Alloderm was used to close the anterior fascia • The skin was closed primarily • Bringing the rectus muscles close together made his abdominal wall appear normal and he could do situps again

  32. CT scan preop with colored layers of abdominal wall

  33. CT postop was layers colored after surgery

  34. What about here in Mozambique? • Sterilized mosquito netting used for mesh in Ghana Clarke Hernia 2009, Burkino Faso Freundenberg World Journal of Surgery 2006 • Apply materials at hand using new techniques • Ask for help from us for supplies • You have all the experience doing more with less – much like battlefield surgery

  35. Summary • Hernias can be very difficult to fix • Mesh is good - most of the time • Laparoscopic techniques may be better for early return to work and for bilateral and recurrent hernias • Some hernias require multiple techniques both open and laparoscopic • “Do not be the first to take up a new idea or the last to put down an old one” Sir William Osler

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