Ing hernia open vs lap ahm 2013 sept

Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
drmgbhat@gmail.com 1Herniacon Ahmedabad 12-15 Sept, 2013
Medical Director
Nova Medical Centers Pvt Ltd, India
Consultant Surgeon
Minimal Access and Bariatric
Surgery
Nova Specialty Surgery, Koramangala
& Manipal Hospital, Bangalore
Greetings From….
Dr. M G Bhat
MS, FRCS(England), FRCS ( Edinburgh), FICS
DMLE (Law), DMIRCSEd (Informatics)

Inguinal Hernia
Open Hernia Repair
Is 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;9-16
4. 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 done
by Lap Surgeons
Open:
Done by
All other
Surgeons

• 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
TA83 Hernia
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 anesthetic
2. First or Recurrent
3. 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 importantthe most important
prognostic factor.prognostic factor.
The Skills and Experience of the SurgeonThe Skills and Experience of the Surgeon
are more important than the type ofare more important than the type of
repair.repair.
Wantz,Hernia,1994Wantz,Hernia,1994

Operate or Not in Hernia ?
• Very High Surgical Risk
Life Expectancy Limited
Refuse Repair
Small & Asymptomatic Hernia
Can
Conside
r
Watchfu
l
Waiting
Can
Conside
r
Watchfu
l
Waiting
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 2013
Surgeons Performance data to be
available from July

Thank you

Ing hernia open vs lap ahm 2013 sept

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