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What inguinal hernia operation and why?

What inguinal hernia operation and why?. Brian Jacob, MD FACS Associate Clinical Prof Surgery Laparoscopic Surgical Center of NY Mount Sinai Medical Center New York City, NY. TEP vs. TAPP. More than 12,000 patients NO differences for recurrence rates, vascular injuries, and OR time TEP

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What inguinal hernia operation and why?

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  1. What inguinal hernia operation and why? Brian Jacob, MD FACS Associate Clinical Prof Surgery Laparoscopic Surgical Center of NY Mount Sinai Medical Center New York City, NY

  2. TEP vs. TAPP • More than 12,000 patients • NO differences for recurrence rates, vascular injuries, and OR time • TEP • More conversions to another type of procedure • May be harder to learn • TAPP • Slightly higher • Intraabdominal adhesions • Trocar site hernias • Visceral injuries Wake BL, McCormack K, Fraser C, Vale L, Perez, Grant A. 2008. The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd

  3. TEP vs. TAPP: Only one RCT • 1 RCT (n=52) • Length of stay was shorter in the TEP group • (mean difference: ‐0.70 days, 95% CI ‐1.33 to ‐0.07; p=0.03) • No differences in OR time, LOS, recurrence, return to activity Schrenk, British Journal of Surgery 1996

  4. 10 year experience with laparoscopic hernias • N=1388 (1903 hernias) • 1561 (82%) TEP • Minor complications 6% • Urinary retention (2.7%) • Conversion to a different technique (3.0%) • Major complications 1.3% • Enterotomy* (0.2%) • Bladder injury* (0.3%) * All had lower midline incisions, TAPP Schwab etal. 2002. SurgEndosc

  5. TEP has proven the test of time

  6. Laparoscopic TEP: Retrospective Review • 2,356 patients with 3,100 hernias • 97% TEP and 3% TAPP Dulucq JL, Wintringer P, Mahajna A, SurgEndosc(2009) 23:482–486

  7. Laparoscopic TEP: Retrospective Review • 2,356 patients with 3,100 hernias • 97% TEP and 3% TAPP Dulucq JL, Wintringer P, Mahajna A, SurgEndosc (2009) 23:482–486

  8. Laparoscopic TEP: Retrospective Review • 2,356 patients with 3,100 hernias • 97% TEP and 3% TAPP Dulucq JL, Wintringer P, Mahajna A, SurgEndosc (2009) 23:482–486

  9. TEP vs. TAPP

  10. TEP: Trocars

  11. TEP: great for direct hernia Left groin

  12. TEP: great for femoral hernia Right groin

  13. TEP: great for indirect hernia Left groin

  14. TEP: no peritoneum to close! Right groin

  15. TEP: Outcomes • Quicker return to daily activities • Better Quality of Life outcomes • Less acute and chronic pain complaints • Less intraabdominal morbidities • Overall no difference in recurrence rates* *when performed by experienced groups

  16. TEP: Quality of Life • 1999 – 2006 • N = 180 (90 Lichtenstein and 90 TEP) • Matched • Recurrence Rates (3% vs 2%) • SF-36 • Physical function, bodily pain, general health Myers E, Browne KM, Kavanagh DO, Hurley M. 2010. World J Surg (ireland)

  17. TEP vs. Lichtenstein: QoL Myers E, Browne KM, Kavanagh DO, Hurley M. 2010. World J Surg (ireland)

  18. TEP: Minimal Chronic Pain • RCT N=1370 665 TEP 705 Open 94% follow-up 5 years 5 years Eklund A, Montgomery A, Bergkvist L, Rudberg C. Swedish Multicenter Trial of Inguinal Hernia Repair by Laparoscopy (SMIL). Brit J Surg. 2010.

  19. TEP vs. Lichtenstein: Chronic Pain * P < 0.001 Eklund A, Montgomery A, Bergkvist L, Rudberg C. Swedish Multicenter Trial of Inguinal Hernia Repair by Laparoscopy (SMIL). Brit J Surg. 2010.

  20. Randomized, Prospective Trial • 365 unilateral inguinal hernias randomly assigned • Shouldice repair (n = 74) • Bassinioperation (n = 93) • Lichtenstein repair (n = 69) • TEP (n = 36) • TAPP (n = 93) Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

  21. Randomized, Prospective Trial • 365 unilateral inguinal hernias randomly assigned • Shouldice repair (n = 74) • Bassinioperation (n = 93) • Lichtenstein repair (n = 69) • TEP (n = 36) • TAPP (n = 93) Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

  22. Randomized, Prospective Trial • 365 unilateral inguinal hernias randomly assigned • Shouldice repair (n = 74) • Bassinioperation (n = 93) • Lichtenstein repair (n = 69) • TEP (n = 36) • TAPP (n = 93) Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

  23. Randomized, Prospective Trial • 365 unilateral inguinal hernias randomly assigned • Shouldice repair (n = 74) • Bassinioperation (n = 93) • Lichtenstein repair (n = 69) • TEP (n = 36) • TAPP (n = 93) Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

  24. Randomized, Prospective Trial • 365 unilateral inguinal hernias randomly assigned • Shouldice repair (n = 74) • Bassinioperation (n = 93) • Lichtenstein repair (n = 69) • TEP (n = 36) • TAPP (n = 93) Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

  25. TEP: Recurrences • no significant difference between lap and open • Surgeons who specialized in one method of hernia repair appeared to have excellent outcomes whenever they operated Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

  26. TAPP: early internal hernia through peritoneal defect

  27. TAPP: early trocar site hernia

  28. TAPP: late adhesions

  29. TAPP vs TEP: bowel obstruction • TAPP repairs • Higher trocar site hernia • Higher occurrence of bowel obstruction • 0.5% (6/1,157) versus 0.07% (1/1,357) for TEP • Adhesions to peritoneal closure site Bringman S, Blomqvist P (2005) Intestinal obstruction after inguinal and femoral hernia repair: a study of 33,275 operations during 1992–2000 in Sweden. Hernia 9:178–183

  30. Indications / recommendations TEP TAPP • All Primary Hernia • (unilateral or bilateral) • All Recurrences • Following open hernia repair • Prior lower midline incisions and prostatectomy*

  31. Primary Hernia with history of lower abdominal surgery • Outcomes‐ TEP • 1388 patients/10 years • 171 previous lower midline incision • Enterotomy: 3 • All in early experience • Cystotomy: 4 Schwab JR. et al. SurgEndosc. 2002

  32. Indications / recommendations TEP TAPP • Primary Hernia • (unilateral or bilateral) • Recurrences • Following open hernia repair • Prior abdominal surgical history, including lower midline and prostatectomy*

  33. Incarcerations / strangulations

  34. Indications / recommendations TEP TAPP Incarcerations or strangulations • Primary Hernia • (unilateral or bilateral) • Recurrent hernia • Following open hernia repair • Prior abdominal surgical history, even involving lower midline

  35. Scrotal Hernias

  36. Indications / recommendations TEP TAPP Incarcerations or strangulations Scrotal hernias • Primary Hernia • (unilateral or bilateral) • Recurrent hernia • Following open hernia repair • Prior abdominal surgical history, even involving lower midline

  37. Inguinodynia: tack

  38. Inguinodynia: recurrence

  39. Indications / recommendations TEP TAPP Incarcerations or strangulations Scrotal hernias Inguinodynia • Primary Hernia • (unilateral or bilateral) • Recurrent hernia • Following open hernia repair • Prior abdominal surgical history, even involving lower midline

  40. Recurrence after TEP or TAPP

  41. Indications / recommendations TEP TAPP Incarcerations or strangulations Scrotal hernias Inguinodynia Recurrence After TEP or TAPP • Primary Hernia • (unilateral or bilateral) • Recurrent hernia • Following open hernia repair • Prior abdominal surgical history, even involving lower midline

  42. Female, palpable inguinal hernia, but also a history of Pfennensteil

  43. Female, palpable inguinal hernia, but also a history of Pfennensteil

  44. Indications / recommendations TEP TAPP Incarcerations or strangulations Scrotal hernias Inguinodynia Recurrence After TEP or TAPP Women with previous Pfenensteil • Primary Hernia • (unilateral or bilateral) • Recurrent hernia • Following open hernia repair • Prior abdominal surgical history, even involving lower midline

  45. When not to do a TEP? • GIANT inguinal scrotal incarceration – TAPP

  46. When not to do a TEP? • GIANT inguinal scrotal incarceration – TAPP • Contraindication to laparoscopy (or general anesthesia)

  47. When not to do a TEP? • GIANT inguinal scrotal incarcerations • Contraindication to laparoscopy or general anesthesia • Morbid obesity – TAPP

  48. Not all hernias need to be fixed • Evidence to support watchful waiting until symptoms worsen without adverse events • Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men: A randomized clinical trial. Fitzgibbons RJ etal. JAMA 2006. • Observation or Operation for Patients with an Asymptomatic Inguinal Hernia: A randomized clinical trial. O’dwyer PJ etal. Annals Surg. 2006 • Does delaying repair of an asymptomatic hernia have a penalty? Thompson JS etal. Am J Surg. 2008

  49. Conclusions • Establish and individualize goals • There is no “one BEST” approach • A hernia specialist should be familiar with all available options • Each method has its merits and its disadvantages • Utilize the technique you are most familiar with , but have back up plans for specific scenarios

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