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Open vs Lap Hernia Repair: Which is Better?

Open vs Lap Hernia Repair: Which is Better?. R. Matthew Walsh, M.D., F.A.C.S. Vice Chairman, Department of General Surgery. Laparoscopy Versus Open Tension Free. Recurrences Return to Work/Normal Function/QOL Post Operative/Chronic Pain Operative Complications Cost.

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Open vs Lap Hernia Repair: Which is Better?

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  1. Open vs Lap Hernia Repair:Which is Better? R. Matthew Walsh, M.D., F.A.C.S. Vice Chairman, Department of General Surgery

  2. Laparoscopy Versus Open Tension Free • Recurrences • Return to Work/Normal Function/QOL • Post Operative/Chronic Pain • Operative Complications • Cost

  3. Abdominal wall hernia repairs in 2003: Inguinal 770,000 Umbilical 175,000 Incisional 105,000 Epigastric/Spigelian 80,000 Femoral 30,000 87% performed as outpatient $2.5 billion/year surgical fees

  4. Current Surgical Approaches Canada USA 1999 2003 Lichtenstein 16% 37% Plug and Patch 20% 34% Laparoscopic 15% 14% Bassini 23% Shouldice 11%

  5. Recurrence • Causes Are Different • Incidence Altered Surgical Expertise and Age Laparoscopic Hernia Specialist True General Surgeon Less Effect and Better Studied in Open • Learning Curve Dilemna Lap: 30-250 cases Most Experienced <5% Recurrence Least Experienced 20% Recurrence Open: 5 Cases For <5% Recurrence  Expect Higher Recurrence With Lap Hernia

  6. Open (Medial) Incomplete Dissection Missed Hernia Mesh Shrinkage Mesh Too Small Laparoscopic (Lateral) Incomplete Dissection Missed Hernia Mesh Shrinkage Mesh Too Small Incomplete Sac Reduction Mesh Migration/Rolling Inadequate Fixation Inexperience Causes of Recurrence

  7. Lap Vs Open VA Cooperative Trial 456 • Trial Evaluating Effectiveness Not Efficacy • Randomization of 1983 Patients, 85% F/U at 2 Years Recurrence OR Complications OR Lap 10.1% 2.2 39.0% 1.3 Open 4.0% 33.4% Lap Hernia Higher Recurrence, Complications (with pain) and Costs Neumayer, EIM, 2004. Hawn, Surgery, 2006. Hynes, Jacs, 2006

  8. Laparoscopic Experience and Age Outcome Predictor Surgeon Age AOR pValue Recurrence Experienced >45 vs <45 0.2 0.036 Inexperienced >45 vs <45 1.72 0.45 Experienced Surgeon >250 Lap Repairs Neumayer, Ann Surg, 2002

  9. Laparoscopic Recurrence: Experience + Age Surgeon Mean SD Range Experience Age No. Recurrence (%) (%) High (>250) <45 2 5.8% 8.2 0-12 >45 6 2.6% 4.1 0-8 Low (<250) <45 32 3.4% 5.9 0-18 >45 15 18.3% 26.5 0-100 Neumayer, Ann Surg, 2005

  10. Criticisms of the VA Cooperative Trial • Poor Operative Quality Control • Results Indicate Poor Technique High Recurrence High Conversion High Complications

  11. Return To Normal Function Lap Vs Open • Complex Socioeconomic Issues Cultural Economic Motivation Work Status • Effects Cost Considerations Indirect Costs  Improved Early Function in Lap Hernia

  12. Lap Vs Open Post Op Pain • Major Morbidity Issue With Open Repair Chronic Pain Reported In Up To 20% Effected By Age • No Pain Association in Open Repair Type of Hernia Hernia Size Surgeon Experience Incision Length Operative Time Planned Nerve Transection • Increased Perioperative Pain In Open • Equivalent Chronic Pain

  13. VA Study Multivariable Models of Patient Satisfaction At 1 Year Satisfaction with Operation Parameter Adjusted OR p Value Age < 58 year 0.46 0.0006 Recurrence (yes v no) 0.07 <0.0001 Neuralgia (yes v no) 0.11 <0.0001 Other Complications (yes v no) 0.38 0.001 Hawn, Surgery, 2006

  14. Visceral Injuries in Randomized Trials L: Lichtenstein

  15. Meta-Analysis Summary: Laparoscopy vs. Lichtenstein

  16. Costs Lap Vs Open • Direct Costs Show Laparoscopic Disadvantage Longer Operative Time Disposables Tackers • Total Costs Including Socioeconomic Factors Return to Productivity Recurrence Rate Complication • Cost Modeling Alters Conclusions

  17. Laparoscopy Versus Open Tension Free • Recurrences • Return to Work/Normal Function/QOL • Post Operative/Chronic Pain • Operative Complications • Cost  Open Tension-Free Repair is the Good Standard Lab Repairs are Suitable Alternative, Surgeon Dependent

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