minimally invasive advances in awr tommy h lee, md creighton university omaha, ne
TRANSCRIPT
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Minimally Invasive Minimally Invasive Advances in AWRAdvances in AWRTommy H Lee, MDTommy H Lee, MD
Creighton UniversityCreighton University
Omaha, NEOmaha, NE
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Nothing to DiscloseNothing to Disclose
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OverviewOverview
Laparoscopic ventral hernia repairLaparoscopic ventral hernia repair
Laparoscopic component separationLaparoscopic component separation
Hybrid proceduresHybrid procedures
Which approach to use?Which approach to use?
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Incisional/Ventral Incisional/Ventral Hernia:Hernia:The FactsThe Facts
A Frequent Complication of LaparotomyA Frequent Complication of Laparotomy
3% to 13% of All Laparotomies3% to 13% of All Laparotomies
4 to 5 Million Laparotomies Annually in the US4 to 5 Million Laparotomies Annually in the US
= 400,000 To 500,000 Incisional Hernias= 400,000 To 500,000 Incisional Hernias
= 200,000 Repairs= 200,000 Repairs
• The American Journal of Surgery, Vol 197, No The American Journal of Surgery, Vol 197, No 1, January 20091, January 2009
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““Traditional” Hernia Traditional” Hernia RepairRepair
OpenOpen
+/- Mesh+/- Mesh
OnlayOnlay
InlayInlay
UnderlayUnderlay
Component SeparationComponent Separation
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Laparoscopic RepairLaparoscopic Repair
Wide overlap (3? 4? 5cm?)Wide overlap (3? 4? 5cm?)
+/- Transfascial sutures+/- Transfascial sutures
+/- Primary closure of defect+/- Primary closure of defect
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Why Laparoscopic?Why Laparoscopic?Open vs. LaparoscopicOpen vs. Laparoscopic
PROPRO
↓ ↓ Operative TimeOperative Time
↓ ↓ Risk of Serious Risk of Serious Complications Complications
↓ ↓ CostCost
Muscle Muscle Approximation → Approximation → Better Functional Better Functional ResultResult
CONCON↑ Infection ↑ Infection Rate? ↑ Recurrence Rate? ↑ Recurrence Rate? Greater Post Rate? Greater Post Operative Pain? Operative Pain? Longer Time for Longer Time for Return to Usual Return to Usual ActivitiesActivities
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Bisgaard et al (2009)Bisgaard et al (2009)
All patients aged 18 years or older who had All patients aged 18 years or older who had elective surgery for incisional hernia in elective surgery for incisional hernia in Denmark between 1 January 2005 and 31 Denmark between 1 January 2005 and 31 December 2006 December 2006
2896 Incisional hernia repairs2896 Incisional hernia repairs
1872 Open/1024 Laparoscopic1872 Open/1024 Laparoscopic
2754 Primary /142 Recurrent2754 Primary /142 Recurrent
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Bisgaard et al (2009)Bisgaard et al (2009)
Unsatisfactory resultsUnsatisfactory results
Severe complication rate 3.5%Severe complication rate 3.5%
Mortality rate 0.4%Mortality rate 0.4%
Reality of the disease?Reality of the disease?
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•73 Laparoscopic vs 73 Open repairs73 Laparoscopic vs 73 Open repairs
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Itani et al (2010)Itani et al (2010)
Laparoscopic - fewer complications, more Laparoscopic - fewer complications, more seriousserious
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8 RCTs, 536 patients8 RCTs, 536 patients
Hernia 23.2 to 141.2 cmHernia 23.2 to 141.2 cm22
F/U 6 to 40.8 monthsF/U 6 to 40.8 months
British Journal of Surgery 2009; 96: 851–858British Journal of Surgery 2009; 96: 851–858
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Forbes et al (2009)Forbes et al (2009)
LaparoscopicLaparoscopic
No difference in recurrenceNo difference in recurrence
Fewer wound complicationsFewer wound complications
Laparoscopic at least equivalent to open repairLaparoscopic at least equivalent to open repair
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Laparoscopic Ventral Laparoscopic Ventral Hernia TechniqueHernia Technique
General anesthesia / Antibiotic prophylaxisGeneral anesthesia / Antibiotic prophylaxis
Table to table PrepTable to table Prep
Insufflation needle - away from midlineInsufflation needle - away from midline
HassonHasson
Initial 5 mm “Optical Trocar”Initial 5 mm “Optical Trocar”
Three cannulae technique, all in the anterior Three cannulae technique, all in the anterior axillary lineaxillary line
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TechniqueTechnique
Lysis of adhesionsLysis of adhesions
Size defect (avoid oversizing)Size defect (avoid oversizing)
Intra-abdominalIntra-abdominal
Deflate abdomenDeflate abdomen
Primary closure of defect?Primary closure of defect?
Place and secure meshPlace and secure mesh
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Port PlacementPort Placement
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MeshMesh
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FastenersFasteners
AbsorbableAbsorbable
Slow-absorbingSlow-absorbing
No long-term foreign bodyNo long-term foreign body
?Adequate fixation?Adequate fixation
Non-absorbableNon-absorbable
ProtackProtack
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FastenersFasteners
Depth of fixation limited!Depth of fixation limited!
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Abdominal Wall FixationAbdominal Wall Fixation
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Abdominal Wall SuturesAbdominal Wall Sutures
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Tricks of the TradeTricks of the Trade
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Marking of the Marking of the ProsthesisProsthesis
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Primarily close the Primarily close the defectdefect
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Securing the meshSecuring the mesh
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Laparoscopic Laparoscopic Component SeparationComponent Separation
Why laparoscopic?Why laparoscopic?
Fewer wound complicationsFewer wound complications
SeromaSeroma
InfectionInfection
Flap necrosisFlap necrosis
Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.
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Laparoscopic Laparoscopic Component Separation - Component Separation - TechniqueTechnique
http://www.sages.org/video/details.php?id=100888
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Is it effective?Is it effective?
Laparoscopic component Laparoscopic component separation achieved 86% separation achieved 86% advancement compared advancement compared to opento open
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Rosen et al.Rosen et al.
External oblique releaseExternal oblique release
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Is it effective?Is it effective?
Comparable amount of releaseComparable amount of release
Tranversus abdominus and posterior sheath release compared to Tranversus abdominus and posterior sheath release compared to traditional ext. oblique + post. sheath releasetraditional ext. oblique + post. sheath release
p values not significantp values not significant
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Is it effective?Is it effective?Large series lackingLarge series lacking
7 patients, average follow-up of 4.5 months7 patients, average follow-up of 4.5 months
External oblique released laparoscopicallyExternal oblique released laparoscopically
Posterior sheath released as necessary (open)Posterior sheath released as necessary (open)
Alloderm underlayAlloderm underlay
1 SSI, 1 hematoma, 1 resp failure1 SSI, 1 hematoma, 1 resp failure
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Is it effective?Is it effective?
Posterior sheath release followed by ext. oblique releasePosterior sheath release followed by ext. oblique release
+/- mesh+/- mesh
7 laparoscopic, 30 open, 1 year follow-up7 laparoscopic, 30 open, 1 year follow-up
Fewer complications in laparoscopic groupFewer complications in laparoscopic group
No ischemia, wound infection, dehiscenceNo ischemia, wound infection, dehiscence
Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.
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Is it effective?Is it effective?
5 patients, less than 1 year follow-up5 patients, less than 1 year follow-up
Laparoscopic ext oblique releaseLaparoscopic ext oblique release
4 had mesh underlay (biologic)4 had mesh underlay (biologic)
2 mild wound complications2 mild wound complications
1 recurrence (!)1 recurrence (!)
Am Surg. 75(7). 572-8.Am Surg. 75(7). 572-8.
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Hybrid Procedure?Hybrid Procedure?
Combine elements:Combine elements:
Laparoscopic/Open lysis of adhesionsLaparoscopic/Open lysis of adhesions
Laparoscopic intraperitonal mesh repairLaparoscopic intraperitonal mesh repair
Laparoscopic/Open component separationLaparoscopic/Open component separation
Rives-Stoppa repairRives-Stoppa repair
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Cox et al.Cox et al.
Open lysis of adhesionsOpen lysis of adhesions
Rives-Stoppa repairRives-Stoppa repair
Laparoscopic component separation to mobilize ant. Laparoscopic component separation to mobilize ant. sheathsheath
Bridging mesh as neededBridging mesh as needed
6 patients, F/U 4-14 months6 patients, F/U 4-14 months
No recurrencesNo recurrences
1 recurrent EC fistula1 recurrent EC fistula
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Combined laparoscopic component separation Combined laparoscopic component separation and intraperitoneal mesh placementand intraperitoneal mesh placement
4 patients, 30-100 day follow-up4 patients, 30-100 day follow-up
Good outcomesGood outcomes
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Primary “shoelace” closure Primary “shoelace” closure of defectof defect
Better function?Better function?
Component separation Component separation (laparoscopic) as needed(laparoscopic) as needed
No recurrences at 16.2 No recurrences at 16.2 monthsmonths
Surg Endosc. 2010 Surg Endosc. 2010 Nov 5Nov 5
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Moazzez et al. Surg Technol Int. 2010;20:185-Moazzez et al. Surg Technol Int. 2010;20:185-91.91.
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Moazzez et al (2010)Moazzez et al (2010)
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Moazzez et al (2010)Moazzez et al (2010)
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Moazzez et al (2010)Moazzez et al (2010)
Fasica is closedFasica is closed
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Guidelines... (Ventral Guidelines... (Ventral Hernia Working Group - Hernia Working Group - 2010)2010)
Breuing et al, Surgery (2010), 148(3), pp 544-558. Breuing et al, Surgery (2010), 148(3), pp 544-558.
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ConclusionConclusion
Laparoscopic techniques are being developedLaparoscopic techniques are being developed
Approach needs to be tailored to particular Approach needs to be tailored to particular needs of patientneeds of patient
No “universal” techniqueNo “universal” technique
Advantages/disadvantages to eachAdvantages/disadvantages to each