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 Hospitals 17 April 2004. Evolution of techniques. Tension creating tissue suturing repair Bassini Cooper / McVay Shouldice Tension free mesh repair Lichtenstein Mesh plug

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Repair of Inguinal Hernia: Open or Laparoscopic

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Repair of inguinal hernia open or laparoscopic

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

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

Recent trend (1970-2000)

  • A companion to specialist surgical practice , general and emergency surgery p.86


Tension free mesh repair

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

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

Meta-analysis

  • 5 meta-analyses found in MEDLINE search in the last decade

  • Compare laparoscopic repair with open repair


Meta analysis1

Meta-analysis


Meta analysis laparoscopic vs open

Meta-analysis: Laparoscopic vs Open


Meta analysis laparoscopic vs open1

Meta-analysis: Laparoscopic vs Open


Meta analysis conclusion

Meta-analysis: Conclusion

  • Laparoscopic repair

    • Similar recurrence rate as open repair

    • Less post-op pain

    • Faster return to work

    • Longer operation time


Meta analysis2

Meta-analysis

  • Increase use of tension free mesh repair in late 1990s


Meta analysis3

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


Rct open mesh vs laparoscopic repair1

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 repair2

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 repair3

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 repair4

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

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


Summary

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


Summary1

Summary

  • Large scale RCT is need to evaluate the advantages and shortcomings of both techniques


Summary2

Summary

  • Leigh Neumayer et al

    • RCT in progress

    • n = 2165

    • FU period: 2 years

    • Outcome measures:

      • Recurrence

      • Complications

      • Patient centered outcomes

      • Cost


Our experience

Our Experience

  • Jan 2002 – Sep 2003

  • 220 elective inguinal hernia repair

  • 95% male patients

  • 13% bilateral inguinal hernia

  • 6.4% recurrent hernia


Age distribution

Age distribution

  • Average age: 67

  • Range: 17-90


Type of technique

Type of technique

  • 217 (98.6%) Lichtenstein repair


Anaesthesia

Anaesthesia

  • GA/SA: 55 (25%)

  • LA: 162 (75%)


Length of hospital stay

Length of Hospital Stay


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