Repair of Inguinal Hernia: Open or Laparoscopic
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Repair of Inguinal Hernia: Open or Laparoscopic Dr. YH Ling Department of Surgery Ruttonjee and Tang Shiu Kin Hosp itals 17 April 2004
description
Repair of Inguinal Hernia: Open or Laparoscopic. Dr. YH Ling Department of Surgery Ruttonjee and Tang Shiu Kin Hospitals 17 April 2004. Evolution of techniques. Tension creating tissue suturing repair Bassini Cooper / McVay Shouldice Tension free mesh repair Lichtenstein Mesh plug - PowerPoint PPT Presentation
Transcript of Repair of Inguinal Hernia: Open or Laparoscopic
Repair of Inguinal Hernia: Open or Laparoscopic
Dr. YH LingDepartment of Surgery
Ruttonjee and Tang Shiu Kin Hospitals17 April 2004
Evolution of techniques Tension creating tissue suturing repair
Bassini Cooper / McVay Shouldice
Tension free mesh repair Lichtenstein Mesh plug
Laparoscopic repair Transabdominal preperitoneal repair (TAPP) Total extraperitoneal repair (TEP)
Recent trend (1970-2000)
A companion to specialist surgical practice , general and emergency surgery p.86
Estimated usage pattern of differnt techniques
0
100
200
300
400
1970 1975 1980 1985 1990 1995 2000
year
Groin
hern
ia re
pairs
(in
thous
ands
) ShouldiceLichtensteinMesh PlugLaparoscopic
Tension Free Mesh Repair
Lichtenstein and Shulman 1987 Procedure under LA
Use of a sheet of 5cm x 10cm prosthetic mesh to reinforce the posterior wall of inguinal canal
Laparoscopic Hernia Repair
First described in early 1990s Different methods
Ring hernioplasty Mesh and plug Intraperitoneal Onlay of Mesh (IPOM) Transabdominal preperitoneal repair (TAPP) Total extraperitoneal repair (TEP)
Meta-analysis
5 meta-analyses found in MEDLINE search in the last decade
Compare laparoscopic repair with open repair
Meta-analysisAuthor (year) No. of
trialsNo. of patients
Repair type
EU Hernia Trialists Collaboration(Ann Surg Mar 2002)
58 11,000 Lap vs Open MeshMesh vs non-meshOpen mesh: flat vs plug vs preperitoneal
EU Hernia Trialists Collaboration (Hernia Mar 2002)
25 4,165 Lap vs Open
Memon 2003 29 5,588 Lap vs OpenChung 1999 14 2,471 Lap vs OpenVoyles 2002 27 4,688 Lap vs Open
Meta-analysis: Laparoscopic vs OpenAuthor (year) Recurrence Operation time Post-op
pain
EU Hernia Trialists Collaboration(Ann Surg Mar 2002)
(Lap vs open mesh) Similar
Not studied Lap: less
EU Hernia Trialists Collaboration (Hernia Mar 2002)
(Lap vs open mesh)Similar
Lap: longer Lap: less
Memon 2003 Lap: higher (not significant)
Lap: longer Not studied
Chung 1999 Similar Lap: longer Lap: less
Voyles 2002 Similar Not studied Not studied
Meta-analysis: Laparoscopic vs OpenAuthor (year) Post-op
ComplicationsHospital stay
Time to return to work
Costs
EU Hernia Trialists Collaboration(Ann Surg Mar 2002)
Not studied Not studied Not studied Not studied
EU Hernia Trialists Collaboration (Hernia Mar 2002)
Lap: rare but serious
Not studied Lap: less Not studied
Memon 2003 Lap: less Lap: shorter
Lap: less Not studied
Chung 1999 Not studied Not studied Lap: less Not studied
Voyles 2002 Not studied Not studied Lap: less Lap > open
Meta-analysis: Conclusion
Laparoscopic repair Similar recurrence rate as open repair Less post-op pain Faster return to work
Longer operation time
Meta-analysis
Increase use of tension free mesh repair in late 1990s
Estimated usage pattern of differnt techniques
0
100
200
300
400
1970 1975 1980 1985 1990 1995 2000
year
Groin
hern
ia re
pairs
(in
thous
ands
) ShouldiceLichtensteinMesh PlugLaparoscopic
Meta-analysis
Tension free mesh repair has a lower complication rate and shorter convalescence period then tissue suture repair
(Kark 1995)
Most meta-analyses are not comparing open mesh repair and laparoscopic repair
RCT: Open mesh vs Laparoscopic repair
MEDLINE search from 1998-2003
Favor Laparoscopic Repair Wellwood 2003 Douek 2002 Bodil Andersson 2003
Favor Open Mesh Repair Marcello Picchio 1999 Paganini 1998
RCT: Open mesh vs Laparoscopic repair
Diversity of results in different studies concerning Post-op pain Complications rate Operation time Time to return to work
RCT: Open mesh vs Laparoscopic repair
Heterogeneous study design Sample size: 50-400 Subjective endpoints not reported in a standard,
quantified manner Post-op pain Return to normal activity Calculation of cost (direct and indirect)
Wide range of FU period 4 weeks to 5 years
Difficult to draw accurate conclusions
RCT: Open mesh vs Laparoscopic repair
Wellwood et al 1998 UK RCT n=400 Lichtenstein (under LA) vs TAPP (under GA)
RCT: Open mesh vs Laparoscopic repair
Wellwood et al 1998 UK Results:
Laparoscopic repair Less post-op pain Fewer complications, except of urinary retention Better patient’s perception of health at 1 month Shorter period of convalescence Higher hospital cost
NICE recommendation
“First time hernias of the groin ought to have open repairs and that laparoscopic (TEP) repair should only be considered for bilateral and recurrent hernias and be performed in specialist units.”
Jan 2001
Open mesh repair
Laparoscopic repair
Anaesthesia LA Obligatory GA
Patient selection
Age, physical infirmity, co-morbid condition not rejected
Not suitable for those with co-morbidity and cardiopulmonay diseases
Operation time Shorter Longer
Learning curve Short Long
Open mesh repair
Laparoscopic repair
Complications Minimal Rare but potential serious complications:
Bowel injuryBladder injuryMajor vessel injury
Return to work and daily activities
Early Earlier
Hospital expense Low HighGAInstrumentsLonger OT time
Summary
There is an increase use of tension free mesh repair e.g. Lichtenstein repair in late 1990s
Meta-analyses and RCT cannot draw accurate conclusion on whether open mesh or laparoscopic repair is more favorable
Summary
Large scale RCT is need to evaluate the advantages and shortcomings of both techniques
Summary
Leigh Neumayer et al RCT in progress n = 2165 FU period: 2 years Outcome measures:
Recurrence Complications Patient centered outcomes Cost
Our Experience
Jan 2002 – Sep 2003 220 elective inguinal hernia repair
95% male patients 13% bilateral inguinal hernia 6.4% recurrent hernia
Age distribution
Average age: 67 Range: 17-90
0
20
40
60
80
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90
Age Distribution
Type of technique
217 (98.6%) Lichtenstein repair
Lichtensteinrepairothers
Anaesthesia
GA/SA: 55 (25%) LA: 162 (75%)
GA/SALA
Mesh Repair 2002-2003
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n 02
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Jul
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3
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Jul
No. ofpatients
GA/SALA
Mesh Repair 2002-2003
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entag
e und
er L
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)
Length of Hospital Stay
0
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0 1 2 3 4 5 6 7 8 9 10length of stay ( days)
no. o
f pati
ents
LAGA/SA
