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Objectives. Appreciate the history and evolution Understand the various approaches Have knowledge of the complications and outcomes Not an attempt to teach how. Inguinal Hernia

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    1. LAPAROSCOPIC INGUINAL HERNIA REPAIR Jeffrey S. Bender, MD, FACS University of Oklahoma College of Medicine

    2. Objectives Appreciate the history and evolution Understand the various approaches Have knowledge of the complications and outcomes Not an attempt to teach how

    3. Inguinal Hernia The Problem Very common Recurrence rates still as high as 15% Increased recognition that mesh necessary Tension-free repairs

    4. Laparoscopic Hernia Second most common laparoscopic procedure Initial enthusiasm now tempered Technically more difficult than laparoscopic cholecystectomy Patient demand not as great

    5. History First performed with clips 1979 (Ger) Didnt become popular until laparoscopic cholecystectomy Initial series (1990) reported plug only Plug migration a problem: fixation

    6. History (cont) Plug: recurrence rate of 25% Realization that patch necessary Recognition of defect in transversalis fascia Three currently used techniques

    7. Transabdominal Preperitoneal Herniorrhaphy (TAPP) First reported 1991 Closure of peritoneum required Easier to learn Risk of bowel injury

    8. Intraperitoneal Onlay Mesh Herniorrhaphy (IPOM) First reported 1992 Technically the easiest (no retro-peritoneal dissection) Anecdotal: adhesion of bowel to mesh Not a problem in only large series published

    9. Totally Extraperitoneal Herniorrhaphy (TEPP) First reported 1993 Similar to Stoppa technique Avoid bowel injuries Learning curve reportedly more difficult

    10. Early Results 444 repairs in 375 patients, 1991-1994 Mostly TEPP; single surgeon Recurrence rate 0.7% Overall complication rate 2.0% Two operations for SBO Fielding Aust NZ J Surg, 1995

    11. 869 hernias in 686 patients, 1991-1992 TAPP, IPOM, multi-institutional Recurrence rate 4.5% Overall complication rate 17.1% One bowel perforation, one bladder injury, one SBO Fitzgibbons, et al. Ann Surg, 1995 Early Results

    12. 600 repairs in 493 patients, 1991-1994 TAPP, TEPP, single institution Recurrence rate 1.2% (TAPP > TEPP) Overall complication rate 2.0% 3 bowel injuries, 2 bladder injuries, 1 SBO (port) Ramshaw, et al. Surg Endosc, 1996 Early Results

    13. Effective repair Probable shorter convalescence No long term data Serious complications in 2-4:1000 Summary of Early Results

    14. Randomized Trial #1 487 TEPP vs. 507 open, 1994-1995 One year follow-up 6 wound infections open vs. 0 in TEPP (p=0.03) TEPP had quicker recovery, back to work, etc.

    15. Recurrence: 6.0% open vs. 3.0% TEPP (p=0.05) 24 conversions to open operation in laparoscopic group 7 major hemorrhage in laparoscopic group vs. 2 in open group Open operation not standardized (only 3% had mesh) Liem, et al. NEJM, 1997 Randomized Trial #1

    16. 496 laparoscopic vs. 460 open One year follow-up Complications: 29.9% lap vs. 43.5% open (p=.001) Return to activity: 10 days lap vs. 14 days open (p=.004) Randomized Trial #2

    17. Persistent groin pain: 28.7% lap vs. 36.7% open (p=.018) Recurrence: 1.9% lap vs. 0.0% open (p=.017) 3 major complications in laparoscopic group MRC Group Lancet, 1999 Randomized Trial #2

    18. 989 laparoscopic (90% TEPP) vs. 994 open, 1999-2001 Two year follow-up Complications: 39.0% lap vs. 33.4% open 2 port site hernias, 2 major bleeds in laparoscopic group Randomized Trial #3

    19. 3 deaths in laparoscopic group (1 bowel injury) 1 death in open group Return to activity: 4 days lap vs. 5 days open Laparoscopic had less pain Randomized Trial #3

    20. Primary recurrence: 10.1% lap vs. 4.0% open Recurrent recurrence: 10.0% lap vs. 14.1% open, p=n.s. 250 lap hernias necessary to reduce recurrence rate Open recurrence rate not altered by experience Neumayer et al. NEJM, 2004 Randomized Trial #3

    21. Summary Laparoscopic herniorrhaphy likely less painful Short term outcomes comparable Long term outcomes unknown Small, but real serious complication rate Experience is key

    22. Current Practice Discuss, but dont propose for primary Good option for recurrent (especially early) or bilateral Possible advantage in obese High index of suspicion for complications

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