Slide 1
Andrew S. Wright MD
Director, UW Medicine Hernia Center
Twitter: @andrewswrightEmail: [email protected]
Open vs. MIS Inguinal Hernia
Types of hernia repairOpen TissueHigh LigationBassiniMcVayHalsteadShouldiceDesardaMarcyOpen Anterior RepairLichtensteinModified LichtensteinOpen Posterior RepairPlugOnStepStoppaOpen Hybrid repairPlug/patchPHS/UHSLap RepairTEPTAPPrTAPPeTEPIPOM
Types of hernia repairOpen TissueHigh LigationBassiniMcVayHalsteadShouldiceDesardaMarcyOpen Anterior RepairLichtensteinModified LichtensteinOpen Posterior RepairPlugOnStepStoppaOpen Hybrid repairPlug/patchPHS/UHSLap RepairTEPTAPPrTAPPeTEPIPOM
Lichtenstein Repair is Gold Standard
Not all hernias are the same!
Not all hernias are the same!
Hernia Outcomes that Matter
Hernia Outcomes that MatterRecurrence2-5%Highly dependent on Surgeon experience and volume
Outcomes that matter - PainChronic Pain8-20% Mesh sensation1-2% Daily pain0.1% Disabling
Outcomes that matter - PainChronic Pain8-20% Mesh sensation1-2% Daily pain0.1% Disabling770,000 hernia repairs annually
Outcomes that matter - PainChronic Pain8-20% Mesh sensation1-2% Daily pain0.1% Disabling770,000 hernia repairs annually77,000 patients with disabling pain
Outcomes that matter - Pain
Secondary OutcomesCostOR timeReturn to workCosmesis
Option: Watchful WaitingAcute event 1.8/1,000 patient yearsNo limitation on exercise or activity
Option: Watchful WaitingAcute event 1.8/1,000 patient yearsNo limitation on exercise or activity
Crossover 76% at 7 years
Tissue Repair: why?20% Google searches for health information
Tissue Repair: why?20% Google searches for health information
Tissue Repair: why?20% Google searches for health information
Option 1: Tissue RepairShouldice
ShouldiceHighly selected patientTechnical and operator dependent
ShouldiceCochrane review 2012 Shouldice vs. other open tissue repairs
Open Mesh (Lichtenstein) RepairAdvantagesQuickReproducibleLocal anestheticLow recurrenceDisadvantagesForeign BodyProximity to nerves
ShouldiceCochrane review 2012 Shouldice vs. mesh repairs
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ShouldiceCochrane review 2012 Shouldice vs. mesh repairs
No decrease in chronic pain in Shouldice vs. Lichtenstein
Types of hernia repairOpen TissueHigh LigationBassiniMcVayHalsteadShouldiceDesardaMarcyOpen Anterior RepairLichtensteinModified LichtensteinOpen Posterior RepairPlugOnStepStoppaOpen Hybrid repairPlug/patchPHS/UHSLap RepairTEPTAPPrTAPPeTEPIPOM
Lichtenstein Repair is Gold Standard
LichtensteinKey step!Identification and preservation of nerves
LichtensteinKey step!Identification and preservation of nerves
1/3 Reduction in pain at 3 months with intra-op Marcaine nerve block
Lichtenstein modificationsno-suture glue technique (TIMELI trial)Significant reduction in disabling painNo difference in recurrence
ProGrip
ProGrip mesh
ProgripPotential benefitsReduced risk of nerve injuryFaster OR timePotential disadvantagesIncreased costIncreased inflammatory reactionSeveral single center RCTs UnderpoweredNo difference in chronic pain or recurrencePossible increase in foreign body sensation
Options: Open Preperitoneal GroinMesh PlugPHS Prolene Hernia SystemUHSONSTEPInsightraKugelTREPP (transrectus preperitoneal)
Outcomes of open preperitoneal repairMost proprietary systems lacking data3 year outcomes no different than standard Lichtenstein
My RecsOpen preperitoneal repairs burn bridgesPlug migrationMeshomaNo evidence that any proprietary system better than Lichtenstein
Option: Open Preperitoneal (Midline)Stoppa Repair Maximally invasive
Stoppa Repair
MIS Inguinal Hernia Repair
Laparoscopic RepairAdvantagesLess short term and chronic pain, Faster RecoveryAddress bilateral hernias, femoral herniasAvoid ilioinguinal and iliohypogastric nerves
Laparoscopic RepairDisadvantagesTechnically more challengingBetter outcomes in RCTs and in expert hands
Lap vs Open: What Does the Data Say?Neumayer L et al. NEJM 2004: 350(18); 1819-1827.Multicenter randomized trial, VA1983 patientsTwo year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%
Lap vs Open: What Does the Data Say?Neumayer L et al. NEJM 2004: 350(18); 1819-1827.Multicenter randomized trial, VA1983 patientsTwo year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%Concluded: primary unilateral hernias should be repaired with OIHR
Lap vs Open: What Does the Data Say?Neumayer L et al. NEJM 2004: 350(18); 1819-1827.Multicenter randomized trial, VA1983 patientsTwo year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%Concluded: primary unilateral hernias should be repaired with OIHRCritique:Average age of pts was high, health related QOL low c/w general populationVA PopulationSurgeon inexperience/learning curveThose with >250 cases had recurrence rate