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NEW ZEALAND:population 4.6M

Auckland:population 1.5M

Size: NZ = UK

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NEW ZEALAND

POLAND

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LAPAROSCOPIC HERNIA REPAIR IN NZ

Public sector no data

Private sector• New Zealand 50% laparoscopic• Auckland 80% laparoscopic

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LAPAROSCOPY AUCKLAND•

Purpose built laparoscopic surgical unitopened 2001• Annually: 1300+ surgical procedures

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LAPAROSCOPIC EXPERIENCE (AB)

• Laparoscopic hernia repairs 6280

•

Laparoscopic cholecystectomy 2365Single port 30

• Laparoscopic fundoplication 550

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LAPAROSCOPIC INGUINAL HERNIA REPAIR

First repair 1991

Personal series 6280• TAPP 270• TEP 6010

Recurrences (TEP) 0.2% (12)

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TEP: HOW I DO IT

• Patient preparation• Theatre setup•

Equipment• Operative technique• Economic considerations• Postoperative management• Results• Pain post hernia repair

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PREOP

Consent• open vs. laparoscopic

Day surgery

Preparation•

Limited shave• No catheter• Antibiotic at induction

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Infra-umbilical accessBalloon dissectionIpsilateral rectus sheath

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Purse string around 10mm port (avoid muscle)0 ° laparoscope + 8-10mm Hg pressure

5mm ports in midline (avoid muscle)

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Nurse/assistant same sideInstrument table rotatedLaparoscopic stack shiftedErgodynamically comfortable

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• Identify landmarks: Superior pubic ramusInferior epigastric vessels

• Dissect widely, especially laterally

•

15x10cm mesh lightweight, large pore

• Fix to sup pubic ramus + linea alba (avoidmuscle/fascia)

• Local anaesthetic around umbilicus + inextraperitoneal plane

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Mesh introduction

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L DIRECT INGUINAL HERNIA: COMMENCEMENT

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R INDIRECT INGUINAL HERNIA: TECHNIQU

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R INDIRECT INGUINAL HERNIA: TECHNIQU

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LARGE LIIH: REDUCTION OF SAC

Dissect completely

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REC LDIH: AVOIDANCE OF SEROMA

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ECONOMIC CONSIDERATIONS

Costs: Laparoscopic repair > open repair• Laparoscopic equipment• Disposables

Operating portsInstrumentsBalloon dissectionMeshTacker / glue

• Operation time:most surgeons laparoscopic > open

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COST SAVINGS (AB)

• Reusable instruments• “Home made” balloon dissector •

Flat mesh• Short tacker

• Operating time laparoscopic << open

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• Hasson cannula• Finger large glove• 3-way tap + 60ml syringe

“Home made” balloon dissector

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Cost: short tacker = 2/3 long tacker

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COST SAVINGS

• Reusable ports and instruments• Avoid “package deals” ( balloon+tacker+mesh)• “Home -made” balloon dissector?

• Avoid light weight large pore meshes?• Avoid barrier meshes

• Avoid fixation?• Glue = more expensive• Short tacker?

POSTOP

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POSTOP

• Discharge same day

• Analgesics only if needed

• Encourage activity (no restrictions)

• Review 7-10 days

• Phone review at 3 months

•

Phone review at 12 months

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POSTOP INFORMATION SHEETImportant•

Wound care• Advice on activity• Follow up instructions

More important• Abdominal distension• Constipation likely

Most important….. • Warn of bruising +/- pain in testes• Typically 3-4 days after operation• = Cause of great concern to males• Stops anxious phone calls after work hours!

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Records: Touch rugby day 0Ballroom dancing day 0Bedroom dancing day 0Mowing lawns day 1Basketball day 1Indoor cricket day 1Volleyball day 1Cycling (50km) day 1Rowing (single scull) day 1Round of golf day 1Pig hunting day 2Fishing (117kg marlin) day 2

Skiing day 3Running (10k) day 3Surfing day 5Snowboarding day 6

Pall bearing day 2

NO RESTRICTIONS POSTOP!!

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PAIN POST HERNIA REPAIR

TAPP/TEPN=989

Open MeshN=994

Long term neuralgia or other pain

9.8% 14.3%

TEPN=240

Open Mesh

Chronic pain or discomfort 22.5% 38.3%

Neumayer et al NEJM 2004;350:1819-27

Macintyre et al BJS 2002;89:1476-79

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PAIN POST TEP HERNIA REPAIR AT 3 MONTHS(male, unilateral; groin strain excluded)

Nil Mild Mod Severe

Restriction(N=951)

99.9%(950)

0.1% (1) Nil Nil

Pain or

discomfort(N=951)

91.1%(866)

8.5%(81)

0.4% (4) Nil

Andrew Bowker personal series

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PAIN: NEUROGENIC

• Nerve interference

Care with tacker fixation…

…Should not experience nerve pain

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PAIN: MUSCULOSKELETAL/MYOGENIC

• Muscular interferenceSuture at umbilical access point

Port placementDissection into muscleFixation to muscle

• Mesh contraction against points of fixation= Major cause of chronic (myogenic) pain?

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Dir

F

Ind

CONTRACTION with drag through tissue

+ PAIN

MECHANISM FOR PAIN WITH SOFT TISSUE FIXATIO

Contraction

ContractionContraction

Contraction

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D

F

I

OPTION: NO FIXATION (OR GLUE FIXATION)

No drag…..

but risk of medial recurrence

ContractionContraction

ContractionContraction

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D

F

I

ALTERNATIVE OPTION: MEDIAL BONE FIXATION O

Contraction

No drag

No risk of medial recurrence

Contraction

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Fixation is safe (and important)

• Fixation to muscle/tendon• Fixation medially and laterally

= potential for pain

Mesh contraction unimportant if no soft tissuefixation

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TEP OPERATION: KEY POINTS

• Ports in midline• Dissect side of hernia only• Identify landmarks + maintain orientation (0°

laparoscope better?)

• Wide dissection especially laterally

• Mesh 15x10cm (lightweight wide pore?)• Penetrative fixation: medially only

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END

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