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Repair of Inguinal Hernia: Open or Laparoscopic

Repair of Inguinal Hernia: Open or Laparoscopic. Dr. YH Ling Department of Surgery Ruttonjee and Tang Shiu Kin Hospitals 17 April 2004. Evolution of techniques. Tension creating tissue suturing repair Bassini Cooper / McVay Shouldice Tension free mesh repair Lichtenstein Mesh plug

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Repair of Inguinal Hernia: Open or Laparoscopic

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  1. Repair of Inguinal Hernia: Open or Laparoscopic Dr. YH Ling Department of Surgery Ruttonjee and Tang Shiu Kin Hospitals 17 April 2004

  2. Evolution of techniques • Tension creating tissue suturing repair • Bassini • Cooper / McVay • Shouldice • Tension free mesh repair • Lichtenstein • Mesh plug • Laparoscopic repair • Transabdominal preperitoneal repair (TAPP) • Total extraperitoneal repair (TEP)

  3. Recent trend (1970-2000) • A companion to specialist surgical practice , general and emergency surgery p.86

  4. Tension Free Mesh Repair • Lichtenstein and Shulman 1987 • Procedure under LA • Use of a sheet of 5cm x 10cm prosthetic mesh to reinforce the posterior wall of inguinal canal

  5. Laparoscopic Hernia Repair • First described in early 1990s • Different methods • Ring hernioplasty • Mesh and plug • Intraperitoneal Onlay of Mesh (IPOM) • Transabdominal preperitoneal repair (TAPP) • Total extraperitoneal repair (TEP)

  6. Meta-analysis • 5 meta-analyses found in MEDLINE search in the last decade • Compare laparoscopic repair with open repair

  7. Meta-analysis

  8. Meta-analysis: Laparoscopic vs Open

  9. Meta-analysis: Laparoscopic vs Open

  10. Meta-analysis: Conclusion • Laparoscopic repair • Similar recurrence rate as open repair • Less post-op pain • Faster return to work • Longer operation time

  11. Meta-analysis • Increase use of tension free mesh repair in late 1990s

  12. Meta-analysis • Tension free mesh repair has a lower complication rate and shorter convalescence period then tissue suture repair (Kark 1995) • Most meta-analyses are not comparing open mesh repair and laparoscopic repair

  13. MEDLINE search from 1998-2003 Favor Laparoscopic Repair Wellwood 2003 Douek 2002 Bodil Andersson 2003 Favor Open Mesh Repair Marcello Picchio 1999 Paganini 1998 RCT: Open mesh vs Laparoscopic repair

  14. RCT: Open mesh vs Laparoscopic repair • Diversity of results in different studies concerning • Post-op pain • Complications rate • Operation time • Time to return to work

  15. RCT: Open mesh vs Laparoscopic repair • Heterogeneous study design • Sample size: 50-400 • Subjective endpoints not reported in a standard, quantified manner • Post-op pain • Return to normal activity • Calculation of cost (direct and indirect) • Wide range of FU period • 4 weeks to 5 years  Difficult to draw accurate conclusions

  16. RCT: Open mesh vs Laparoscopic repair • Wellwood et al 1998 UK • RCT • n=400 • Lichtenstein (under LA) vs TAPP (under GA)

  17. RCT: Open mesh vs Laparoscopic repair • Wellwood et al 1998 UK • Results: • Laparoscopic repair • Less post-op pain • Fewer complications, except of urinary retention • Better patient’s perception of health at 1 month • Shorter period of convalescence • Higher hospital cost

  18. NICE recommendation • “First time hernias of the groin ought to have open repairs and that laparoscopic (TEP) repair should only be considered for bilateral and recurrent hernias and be performed in specialist units.” • Jan 2001

  19. Summary • There is an increase use of tension free mesh repair e.g. Lichtenstein repair in late 1990s • Meta-analyses and RCT cannot draw accurate conclusion on whether open mesh or laparoscopic repair is more favorable

  20. Summary • Large scale RCT is need to evaluate the advantages and shortcomings of both techniques

  21. Summary • Leigh Neumayer et al • RCT in progress • n = 2165 • FU period: 2 years • Outcome measures: • Recurrence • Complications • Patient centered outcomes • Cost

  22. Our Experience • Jan 2002 – Sep 2003 • 220 elective inguinal hernia repair • 95% male patients • 13% bilateral inguinal hernia • 6.4% recurrent hernia

  23. Age distribution • Average age: 67 • Range: 17-90

  24. Type of technique • 217 (98.6%) Lichtenstein repair

  25. Anaesthesia • GA/SA: 55 (25%) • LA: 162 (75%)

  26. Length of Hospital Stay

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