Ing hernia open vs lap ahm 2013 sept

Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY

[email protected] 1Herniacon Ahmedabad 12-15 Sept, 2013

Medical DirectorNova Medical Centers Pvt Ltd, India

Consultant SurgeonMinimal Access and Bariatric SurgeryNova Specialty Surgery, Koramangala & Manipal Hospital, Bangalore

Greetings From….

Dr. M G BhatMS, FRCS(England), FRCS ( Edinburgh), FICSDMLE (Law), DMIRCSEd (Informatics)



Inguinal Hernia

Open Hernia RepairIs this the end of the Road?



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



Treatment Options .1

Acute: Irreducible, Strangulated, Obstructed or Uncertain viability of the bowel

Open:

Preferred Approach by most Surgeons

Lap:

Few Published Reports



• Paper Based of the review of literature: 43 articles found: • 16 reported use of Lap • 7 reported exclusive use of Laparoscopy • and were fully reviewed.

• 328 cases• 6 Conversions• Average Stay 4 days• 34 Complications ( Mostly Minor)• 17 Resections ( by lap or mini laparotomy)

Laparoscopic Approach to Incarcerated and Strangulated Inguinal Hernia: S Deeba, E Zacharakis et all. JSLS(2009)13:327-331




Large or Symptomatic Hernia

Open:

Preferred Approach by most Surgeons

Lap:

Preferred-on the expertise the Surgeon



• Size and Type of Hernia

• Technical Capability• Access to Facility• Previous Operations• Cost factors

What Repair ? How to select ?



What techniques in 2013>>>>?

• 95% Open Mesh- Lichtenstein• 5% Laparoscopy

EU Hernia Trialists Collaboration Laparoscopic compared with open methods of groin hernia repair:systematic review of randomized trials. Br J Surg 2000;87:860-7. ….And Many other Publications



Repair Types used in USA (as of 2003)

Procedure Total & (%)

Lichtenstein 229500 (37)

Plug 227000 (34)

Laparoscopy 111500 (14)

Other meshes

65000 (8)

Tissue Repairs

55000 (7)

SS Awad, SP Fagan. Current Approaches to Inguinal Hernia Repair. Am J Surg;2004;188-6;9-16




Recurrent or Bilateral Hernia

Lap:

Preferred Approach. To be doneby Lap Surgeons

Open:

Done by All otherSurgeons



• Laparoscopy safe, comfortable, cost effective

What is Best for – Bilateral ?

A prospective German Study- Schmedt CG, Daubler P, Leibl BJ, Kraft K, Bittner R. Simultaneous bilateral laparoscopic inguinal hernia repair. Surg Endosc. 2002;16:240-244



Recurrent Hernia..?

• Following Open- Lap

• Following Lap - Open



80 yrs/M with IHD and Respiratory Problems ..

What Repair?




High Surgical Risk Patients

Open:

Preferred Approach Under Local Anesthesia

Lap:

Not suitable For GA



Which is Better - Open or Lap ?

N Engl J Med 2004;350:1819-27. (www.nejm.org)Prospective Random Study comparing- Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia. Neumayer L, Giobbie-Hurder A, Jonasson O, et all. for the Veterans Affairs Cooperative Studies Program 456 Investigators

• Lap - Pain Less • Lap – Early Return to Work

• But Higher Risk of Serious Complications and Recurrence



Open Hernia ..When?

• Large Hernia• Complicated Hernia• Lap Recurrent Hernia• Previous Surgery ?



Lap Hernia ..When?

• Fit Patients• Uncomplicated Hernia• Bilateral & Recurrent• Cost Factor??



2004 revised recommendations….• Lap repair to be considered for first time management of unilateral inguinal hernias

2001 Recommendation…. • Open Mesh Repair preferred approach for primary hernia• Laparoscopy for Recurrent and Bilateral Hernia

NICE (National Inst for Clinical Excellence, UK)



National Institute of Health and Excellence(NICE Guidelines) UK

TA83Hernia laparoscopic surgery (review) (TA83)

Technology appraisals TA83 Issued: September 2004



Laparoscopic surgery can be used as an option for repairing inguinal hernia.

As with all surgery, there are some risks involved, which may include serious problems just after the operation, pain or numbness in the area of the operation, and the hernia coming back.

Your doctor should tell you about the risks and benefits of each of the types of surgery (open surgery, or laparoscopic surgery using either the TAPP or TEP methods) before you make a decision on which method to have.

NICE ….



In helping you make this decision you and your doctor should particularly consider: 1. How well you are likely to cope with a general anesthetic2. First or Recurrent3. Unilateral or Bilateral 4. Open or Lap is the best 5. Surgeons Experience

NICE has also said that laparoscopic surgery for inguinal hernia repair by TAPP or TEP should only be performed by specially trained surgeons who regularly carry out the procedure.

NICE ….



BMJ. 2003 May 10;326(7397):1012-3.

Prospective randomized controlled trial of lap vs open

Both with good long term results & low recurrence



The Surgeon FactorThe Surgeon Factor

The Surgeon isThe Surgeon is the most important the most important

prognostic factor.prognostic factor.

The Skills and Experience of the The Skills and Experience of the Surgeon are more important than the Surgeon are more important than the type of repair.type of repair.

Wantz,Hernia,1994Wantz,Hernia,1994




Operate or Not in Hernia ?

• Very High Surgical Risk Life Expectancy Limited Refuse Repair

Small & Asymptomatic Hernia

Can Consider WatchfulWaiting

Can Consider WatchfulWaiting

Safer to Avoid !

Safer to Avoid !



NICE Guidelines 2004

With seemingly similar results and complications the choice between the two procedures should firmly be based on the surgeon’s experience and preference



POEM is the present Philosophy…•Patient

•Oriented •Evidence that •Matters

Patient-Oriented Evidence that Matters(editorial BMJ 2002;325:983)www.infoPOEMs.com/informationmastery.cfm



http://dx.doi.org/10.1136/bmj.f3795 (Published 11 June 2013) BMJ 2013;346:f3795

News: BMJ June 2013Surgeons Performance data to be available from July



Thank you

Ing hernia open vs lap ahm 2013 sept

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