inguinal hernia: future directions brian jacob md facs new york, ny
TRANSCRIPT
Inguinal Hernia: Future Directions
Brian Jacob MD FACS
New York, NY
Peter Drucker
• “The only thing we know about the future is that it will be different.”
November 1909 – November 2005. Influential author, businessman
Inguinal Hernia Repairs: innovation
Access
Mesh
Fixation
Patient Satisfaction
Techniques
Evolution of Inguinal Hernia: Access Techniques
Open
• Stromayr 1559• Lucas-Championnière
1881• Bassini 1889• McVay 1942• Shouldice 1945• Lichtenstein 1987• Stoppa 1989
Laparoscopic
• Ger 1990• Velez and Klein 1990• Others
SILS / NOTES
• Just now being described
1559 - 1989 1990-2008 2009 ---
Sachs M, Damm M, Encke A. 1997. World J Surg. 218-223
Early Inguinal Hernia Repairs
1559 Caspar Stromayr. Practica Copiosa.Great Ideas in the History of Surgery By Leo M. Zimmerman, Ilza Veith
Early Inguinal Hernia Repairs
1559 Caspar Stromayr. Practica Copiosa.Great Ideas in the History of Surgery By Leo M. Zimmerman, Ilza Veith
Inguinal Hernia: Emerging Technologies
• Single Port– Inguinal–Ventral
• NOTES– Transgastric– Transvaginal
Inguinal Hernia: Emerging Technologies
• Single Port– Inguinal–Ventral
• NOTES– Transgastric– Transvaginal
Indications
Inguinal Hernia: Emerging Technologies
• Single Port– Inguinal–Ventral
• NOTES– Transgastric– Transvaginal
Worse Options:
Single Incision Laparoscopic Surgery (SILSTM ): Introduction
• Descriptions as early as 1996• Synonyms
– SPA– LESS– Others
• Rapid growth since 2007
Single Incision Laparoscopic Surgery (SILSTM ): Introduction
• Rapid growth since 2007• Growth precedes proven clinical benefits
Single Incision Laparoscopic Surgery (SILSTM ): Introduction
• Rapid growth since 2007• Growth precedes proven clinical benefits• Demonstrated feasibility in multiple specialties
– General, Colorectal, Bariatrics, Urologic, and Gynecologic
Single Incision Laparoscopic Surgery: Many variations on a single theme
• Skin incision– Location and size
Single Incision Laparoscopic Surgery: Many variations on a single theme
• Skin incision– Location and size
• Entry method– Multiple trocars or single port access device
Single Incision Laparoscopic Surgery: Many variations on a single theme
• Skin incision– Location and size
• Entry method– Multiple trocars or single port access device
• Instrumentation / Scopes
Single Incision Laparoscopic Surgery: Many variations on a single theme
• Skin incision– Location and size
• Entry method– Multiple trocars or single port access device
• Instrumentation / Scopes• Retraction
SILSTM Inguinal Hernia: Introduction
• SILSTM TEP – Filipovic-Cugura J, Kirac I, Kulis T, Jankovic J, Bekavac-Beslin M
• (Surg Endosc April 2009) (Croatia) (routine)
– Jacob BP, Tong W, Katz B, Vine A, Reiner M• (Hernia June 2009) (USA) (SILSTM Port)
– Agrawal S, Shaw A, Soon Y• (Surg Endosc Sept 2009) (UK) (TriPort)
• SILSTM TAPP– Kroh M, Rosenblatt S
• (J Lap Adv Surg Tech A. April 2009) (USA) (Uni-X Single Port System)
– Rahman SH, John BJ• (Hernia. Aug 2009) (UK) (roticulating graspers)
– Menenakos C, Kilian M, Hartmann J• (Hernia. Aug 2009) (Germany) (TriPort)
Source: pubmed.gov as of October 5, 2009 (“single incision hernia”)
Question: What (if anything) is wrong with the current
standard?
Answer: Potentially only cosmesis
Early Experience: TEP
• Animal labs• 2 – 3mm instruments
– Still needed at least one 5 mm• Moved to 2 incision technique• Moved to single incision with multiple
trocars– Sword fighting– Air leaking
• Single port access device Feb 2009
Hernia. June 2009
Hernia. June 2009
Hernia. June 2009
Hernia. June 2009
SILSTM TEP:bilateral inguinal hernia repair
2 week follow-up
25 mm skin incision
SILSTM TEP:bilateral inguinal hernia repair
1 month follow-up
25 mm skin incision
SILSTM TEP:bilateral inguinal hernia repair
1 month follow-up
25 mm skin incision
SILSTM TEP:bilateral inguinal hernia repair
immediate post operative
SILSTM TEP: don’t celebrate too early
SILSTM TEP hernia:initial experience with a single access port
– 8 men with bilateral indirect hernias• One also with an umbilical hernia
– 1 man with unilateral indirect– 1 woman with b/l direct and femoral hernia
• 2 converted to traditional 3 trocars– Peritoneum violated– Inability to reduce an adherent indirect
SILS TEP hernia:initial experience with a single access port
– Mean follow-up 8 months• Incisional pain (1 - 6 days)• Narcotics used for 0 – 4 days• No early recurrences (up to 8 months)• No incisional hernias so far• Open umbilical hernia patient developed seroma
Early lessons learned
• Challenges– Port insertion has a learning curve
Early lessons learned
• Challenges– Learning curves all over again
Early lessons learned
• Challenges–Many ports available
• Are they needed at all?• Is one better than another?
Early lessons learned
• Challenges– Many ports available
• Are they needed at all?• Is one better than another?
– First trocar is blunt, but blind
Early lessons learned
• Challenges– Many ports available
• Are they needed at all?• Is one better than another?
– First trocar is blunt, but blind– Incision size
• Port modifications ARE needed
Early lessons learned
– Unknown outcomes• Seromas ?• Incisional Hernias ?• Costs ?• Let’s be realistic ?
SILSTM Inguinal Hernia: conclusions
• SILSTM TEP, TAPP, IPOM techniques now being described (feasible)– With and without single port access (SPA) devices
• Can be performed with same instruments in use today (may limit additional costs)
• Patients seem to like the single incision concept• Experiences are only in the beginning stages• Future is unknown
– Growth seems inevitable
Inguinal Hernia Repairs: innovationAcc
ess
Mesh
Fixation
Patient Satisfaction
Techniques
Randomized prospective Study of TEP: Fixation vs No Fixation of Mesh
• Jan 2002 – Jan 2004• 40 males underwent lap TEP followed for one year using
10-point VAS for pain followed for a mean of 9 months– (n=20) Heavyweight (100 g/m2) (Prolene) WITH TACKS– (n=20) Heavyweight (108 g/ m2) (Davol 3DM) WITHOUT fixation
• No significant difference in post op pain (p=0.15)• No significant difference in recurrent rates• Did see more urinary retention in group where tacks were
used
Koch CA, Greenlee SM, Larson D, Harrington JR, Farley DR. JSLS. 2006. (Mayo, Minnesota)
Randomized prospective Study of TEP: Fixation vs No Fixation of Mesh
• Conclusions– Use of tacks did not add pain (Is study under powered?)– Avoiding tacks did not change recurrence rates– Avoiding tacks can reduce costs, but keep outcomes the same
Koch CA, Greenlee SM, Larson D, Harrington JR, Farley DR. JSLS. 2006. (Mayo, Minnesota)
Laparoscopic inguinal hernia repair without mesh fixation, early results of a large
randomized clinical trial• Dec 2004 and Jan 2006• 360 males underwent lap TEP (500 hernias) followed for a
mean of 8.2 months. Pain scale used at office visit– Heavyweight (100 g/m2) (Prolene) WITH TACKS– Heavyweight (100 g/ m2) (Prolene) WITHOUT TACKS
• WITH TACKS group had more new pain complaints (p=0.0003)– No significant difference in recurrent rates
• Defect size all less than 2 cm• For bilateral patients, the NO TACK side was 5x more
likely to be more comfortable• Conclusion: tacks may increase pain, costs, and may not
be necessary– ? Better powered than the Mayo Clinic study
Taylor C, Layani L, Liew V etal. Surg Endosc. 2008. (Australia)
Laparoscopic TEP with nonfixation of the mesh for 1,692 hernias
• 3 year retrospective study– Followed for recurrences, pain at one month,
seroma, and urinary retention• Recurrence rate only 0.22%
– Less pain than a cohort of patients who received fixation
– Conclusions: TEP without mesh fixation does not increase recurrence rates and is associated with less pain, urinary retention at 4 weeks
Garg P, Rajagopal M, Varghese V, Ismail M. 2008. Surg Endosc. (Punjab, India)
Novel Concepts: Materials
• Self Adhering Mesh
• Fibrin Glues• Partially absorbing
mesh fibers• Absorbable Tacks
• Lightweight (40 g/m2) polypropylene coated with synthetic glue (adhesix)(cousin biotech, Fr)– Polyvinylpyrrolidone and polyethylene glycol– Disappears in 2 -3 days
• Porcine animal study• Same incorporation as mesh with tacks
Champault G etal. 2008 Hernia. (Paris, France)
Novel Concepts: Materials
• Self Adhering Mesh
• Fibrin Glues• Partially absorbing
mesh fibers• Absorbable Tacks
Novel Concepts: Materials
• Self Adhering Mesh• Fibrin Glues• Partially absorbing mesh fibers• Absorbable Tacks
• poly(glycolide-co-L-lactide) (PGLA).
Stepped Wing
Flat Wing
Want to entirely eliminate morbidity? Don’t operate
• New evidence to support watchful waiting until symptoms worsen without adverse events– Watchful Waiting vs Repair of Inguinal Hernia in
Minimally Symptomatic Men: A randomized clinical trial. Fitzgibbons RJ etal. JAMA 2006.
– Observation or Operation for Patients with an Asymptomatic Inguinal Hernia: A randomized clinical trial. O’dwyer PJ etal. Annals Surg. 2006
– Does delaying repair of an asymptomatic hernia have a penalty? Thompson JS etal. Am J Surg. 2008
Conclusions: inguinal hernia• Laparoscopic TEP / TAPP
– Recurrence rates not different in highly experienced hands– Chronic pain not sig different– May have early advantages for bilateral and recurrent hernias
• Lightweight mesh product – Less pain especially during first 3 months– Quicker return to work / activity – No difference in recurrence rates in experience hands
• Tack fixation may not be necessary if proper overlap of the myopectineal orifice is achieved
• Chronic neuropathic pain with early onset, that responds to nerve blockade (CRPS 2):– Best predictable outcome for relief following neurectomy or
meshectomy
Peter Drucker
• “The best way to predict the future is to create it.”
November 1909 – November 2005. Influential author, businessman
