To Tack or Not to Tack

George S Ferzli, MD, FACS Giancarlo Cires, MD Courage and comfort, all shall yet go well” King John, Act ii, Scene 4 To Tack or Not to Tack

Disclosure George Ferzli, MD, FACS has been a consultant for: Baxter International, Inc. Covidien, Inc. To Tack or Not to Tack

Increase in hernia recurrence? Increase in post-operative pain and cost. Our doubts are traitors, and make us lose the good we oft might win, by fearing to attempt” Measure for Measure, Act i, Scene 5” Why is there a question?

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],"Wisely and slow; they stumble who run fast” Romeo & Juliet, Act ii, Scene 3 Deans GT, Wilson MS, Royston CM, Brough WA. Recurrent inguinal hernia after laparoscopic repair: possible causes and prevention. Br J Surg. 1995; 82:539-541. Why tack?

[object Object],[object Object],Felix et al. Surg Endosc (1998) 12: 226–231 "My endeavours have ever come too short of my desires” Henry VIII, Act iii, Scene 2 Inadequate lateral fixation of the mesh was identified in 11 cases Hernia Recurrence

"Have patience, and endure "Much Ado About Nothing, Act iv, Scene 1 “ Above all, these studies frequently did not specify the dimensions of the hernial defect. The significance of the size of a hernial opening on the recurrence rate remains unknown.” Khajanchee YS, Urbach DR, Swanstrom LL,Hansen PD. Outcomes of laparoscopic herniorrhaphy without fixation of mesh to the abdominal wall. Surg Endosc. 2001; 15: 1102-1107. “ In conclusion, mesh fixation in the TEP technique offers no clinical advantages and increases the cost of the process. Our results recommend limiting the use of mesh fixation in the laparoscopic approach to cases of direct bilateral hernias.” Randomized Clinical Trial of Fixation vs Nonfixation of Mesh in Total Extraperitoneal Inguinal Hernioplasty Alfredo Moreno-Egea MD, Jose Antonio Torralba Martinez, MD, German Morales Cuenca MD, Jose Luis Aquavo Albasini, MD Arch Surg. 2004;139:1376-1379. Is stapling mesh necessary to contain an enlarged or bilateral hernia?

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ferzli et al. Surg Endosc (2004) 18: 523–525 "What wound did ever heal but by degrees ?” Othello, Act ii, Scene 3 Mesh Migration

[object Object],[object Object],[object Object],[object Object],"Tis better to be brief than tedious” Richard III, Act i, Scene 4 Why not tack?

[object Object],[object Object],[object Object],Ferzli et al. J Am Coll Surg. Vol. 188, No. 5, May 1999 "Ignorance is the curse of God, knowledge the wing wherewith we fly to heaven” Henry VI, Act iv, Scene 7 … there may be no difference in recurrence rates Why not tack?

[object Object],[object Object],[object Object],[object Object],Ferzli et al. J Am Coll Surg Vol. 188, No. 5, May 1999 Have more than though showest; speak less than thou knowest; lend less than thou owest” King Lear, Act i, Scene 4 Why not tack? … there may be no difference in recurrence rates

[object Object],[object Object],[object Object],[object Object],Liem MS et al. Ann Surg . Vol 237: 1 Jan 2003 "They that thrive well take counsel of their friends” Venus & Adonis … there may be no difference in recurrence rates Why not tack?

[object Object],[object Object],[object Object],[object Object],Liem MS et al. Ann Surg . Vol 237: 1 Jan 2003 … there may be no difference in recurrence Why not tack?

[object Object],[object Object],[object Object],Liem MS et al. Ann Surg . Vol 237: 1 Jan 2003 … there may be no difference in recurrence Why not tack?

[object Object],[object Object],Ferzli et al. J Am Coll Surg, Vol. 205, No. 2, Aug 2007 "When sorrow comes, they come not single spies, but in battalions” Hamlet, Act iv, Scene 5 … there may be more groin pain Why not tack?

Ferzli et al. J Am Coll Surg, Vol. 205, No. 2, Aug 2007 "There was never yet philosopher that could endure the toothache patiently” Much Ado About Nothing, Act v, Scene 1 Post Herniorrhaphic Groin Pain

[object Object],[object Object],[object Object],Wong J et al . Surg Laparosc Endosc Percutan Tech 2001, 11: 2 Condemn the fault, and not the actor of it” Measure for Measure, Act ii, Scene 2 G Ferzli et al . … there may be more groin pain Why not tack?

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Koch CA et al. JSLS (2006) 10: 457-460 “ How poor are they that have not patience” Othello, Act ii, Scene 3 … there may be more groin pain Why not tack?

[object Object],[object Object],[object Object],[object Object],[object Object],Taylor C et al. Surg Endosc . 2007 Sept 21 "Words without thoughts never to heaven go” Hamlet, Act iii, Scene 3 … there may be more groin pain and no difference in recurrence Why not tack?

Taylor C et al. Surg Endosc . 2007 Sept 21 … there may be more groin pain and no difference in recurrence Why not tack?

[object Object],[object Object],[object Object],[object Object],Taylor C et al. Surg Endosc . 2007 Sept 21 … there may be more groin pain and no difference in recurrence Why not tack?

[object Object],[object Object],[object Object],[object Object],Taylor C et al. Surg Endosc . 2007 Sept 21 "Love all, trust a few, do wrong to none” All's Well that Ends Well, Act i, Scene 1 … there may be more groin pain and no difference in recurrence Why not tack?

Ferzli et al. J Am Coll. Surg. Vol. 188, No. 5, May 1999 "Withold thine indignation, mighty heaven, and tempt us not to bear above our power” King John, Act v, Scene 6 … where to staple – and how many? Why not tack? Khajanchee et al. Surg Endosc (2001) 15: 1102–1107

[object Object],[object Object],[object Object],“ Better three hours too soon than a minute too late” Merry Wives of Windsor, Act ii, Scene 2 An Alternative-Bioglue

[object Object],[object Object],[object Object],Lau H. Ann Surg . 2005; 242: 670-675 “ Its not enough to speak, but to speak true” Midsummer Night’s Dream, Act v, Scene 1 An Alternative-Bioglue

Lau H. Ann Surg . 2005; 242: 670-675 An Alternative-Bioglue

[object Object],[object Object],[object Object],[object Object],Lau H. Ann Surg . 2005; 242: 670-675 "It is the mind that makes the body rich” Taming of the Shrew, Act iv, Scene 3 Why not tack?-bioglue

[object Object],[object Object],[object Object],Why not tack? It is costly. Peach, G. Small bowel obstruction and perforation due to a displaced spiral tacker: a rare complication of laparoscopic inguinal hernia repair. Hernia. 2007 Nov 20 Novik, B. Fibrin glue for securing the mesh in laparoscopic totally extraperitoneal inguinal hernia repair. Surg Endosc (2006) 20: 462–467 Ferzli et al. J Am Coll Surg Vol. 188, No. 5, May 1999

[object Object],[object Object],Defend your reputation, or bid farewell to your good life for ever” Merry Wives of Windsor Act iii, Scene 2 Conclusions

[object Object],[object Object],Conclusions

[object Object],[object Object],"Take honour from me, and my life is done” Richard II, Act i, Scene 1 – at least you know it’s not your staples. Finally

"The elements be kind to thee, and make thy spirits all of comfort: fare thee well !” Antony & Cleopatra, Act iii, Scene 2

To Tack or Not to Tack

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