TEP: issues for debate

Poland October 2012

TEP: ISSUES FOR DEBATEAndrew Bowker Laparoscopy Auckland New Zealand

ISSUES FOR DEBATE: AN INTRODUCTIONEvidence-based practice not necessarily best practiceAny approach to hernia repair can be defended through literature search

My way is the best way!

Based onExperience (6280 lap hernias)Thought about techniqueObservation of other surgeons

TOPICS TO BE DISCUSSED (i)Laparoscopic vs. OpenTEP vs. TAPPTechnical aspects: Balloon dissection / Port placement / 0 vs. 30 laparoscopeMesh: Type / Shape / SizeFixation: none / tacs / titanium vs. absorbable / glueRecovery adviceUse of ultrasound for hernias

TOPICS TO BE DISCUSSED (ii)Particular situationsAbdominal wall scarringIrreducible herniasFemoral herniasSpigellian herniasTEP for sports hernia/groin strainMasterclassHernia recurrence after previous laparoscopic repairTEP after radical prostatectomyLAPAROSCOPIC VS. OPENForMakes mechanical senseAvoids muscle traumaAvoids ilioinguinal and iliohypogastric nervesLess post operative pain (short and long term)Earlier return to full activityLow recurrence rate

AgainstGeneral anaesthesia requiredMore expensive: GA, disposablesLong learning curveNot suitable for all surgeonsTEP VS TAPPFor TEPIntra abdominal adhesions = no problemNo peritoneal incisionNo peritoneal closureFasterIncisional hernia not possible

Against TEPAnatomy more difficult to recogniseHarder to learn/teachLEARNING LAPAROSCOPIC TECHNIQUE

Believe = ideal way to repair inguinal herniasAttend courseObserve expertsBe mentored

KEEP TRYING!

Observe experts (again)

BALLOON DISSECTIONGives clean initial spaceExpensive if commercial balloon usedHome-made option low cost

BALLOON DISSECTIONCan strip inferior epigastric vessels from rectus musclePORT PLACEMENTIn midline

Comfortable, if operating room set up properlyAvoids dissection of contralateral side

Lateral (both sides of midline)

Requires wider dissectionAwkward anglesViolates contralateral side

0 vs 30 LAPAROSCOPE30 Makes orientation difficultGets in the way when working close to the midline , with the ports placed in the midline0 makes it difficult to see around corners; need to learn tricksIs easier to keep orientated (still need care)

LIGHTWEIGHT VS.HEAVYWEIGHT MESHHeavyweight, small poreCheaperGood handling characteristicsContraction up to 30%

Lightweight, large poreMore expensiveLess scarring, less shrinkageLess pain??Poor handling (floppy)Increased recurrences??

12MESH: FLAT VS. MODIFIEDFlat Should sit well if dissection complete

Shaped meshEasier to position (especially when learning)

Slit in mesh (around cord)More pain??Potential for recurrence through slitMESH: SIZESize: 15x10cmSmaller associated with increased recurrence rate (particularly with shrinkage) MESH: PLAIN VS.BARRIER

Barrier mesh (anti-adhesion)May improve handling of lightweight meshExpensive Barrier provides no benefit in TEPFIXATION VS. NO FIXATIONFixation with tacks Secures mesh, especially medial edgeAllows reduction of direct hernia defect

Fixation with glueMore expensive with fibrin glueLess expensive with cyanoacrylateLess pain potential

No fixationCheaper Less pain potentialIncreased recurrence (especially direct hernias)

FIXATION: BONE OR SOFT TISSUE?Bone: no soft tissue injuryStrong fixationSoft tissue (muscle / ligament): cause of chronic pain? FIXATION: TITANIUM OR ABSORBABLE?Titanium tacks: penetrate bone / periosteumAbsorbable tacks:suitable for soft tissue onlyMore expensive

RECOVERY ADVICENo restrictionsMore activity = better recoveryAnalgesics as necessaryEarly return to heavy activity not associated with increased risk of recurrence

Patients are stronger than they ever have been immediately after the operation!ULTRASOUND Limited value

If hernia clinically, adds no further information

If no hernia clinically, probably no herniaUltrasound hernia usually just cord lipomaBut patient believes hernia.. TOPICS TO BE DISCUSSED (ii)Particular situationsAbdominal wall scarringIrreducible herniasFemoral herniasSpigellian herniasTEP for sportsmans hernia/groin strainMasterclassHerniation post previous laparoscopic repairTEP post radical prostatectomyTEP : ABDOMINAL WALL SCARRINGMidline scars (including Pfannensteil)Ignore for unilateral repairsSeparate dissection either side of midline for bilateral repairs

Transverse scars (appendicectomy)Careful dissection to avoid / minimise peritoneal tearingPERITONEAL TEAR R

ENDOLOOP PERITONEAL TEAR L IIH

IRREDUCIBLE HERNIA

Options:(i) Manual reduction under general anaesthesia (ii) Laparoscopic TAPP reduction(iii) Open reduction via skin crease incision in groin and mobilise sac Then TEP

IRREDUCIBLE RIIH

24REDUCTION OF FEMORAL HERNIADefect has tight neck: hernia difficult to reduce

Disrupt Lacuna ligament mediallyDiathermy hook = idealAbnormal obturator vessels easily avoided

FEMORAL HERNIA L

SPIGELLIAN HERNIATEP approach Dissect further cephaladReduce herniaCover with meshFix mesh

SPIGELLIAN HERNIA R

SPORTS HERNIA/GROIN STRAINChronic pain in inguinal area without herniaTender over conjoint tendonPathology uncertainAnatomy at surgery looks normalSupport with mesh from within can help

No guarantees FURTHER LAPAROSCOPIC REPAIR FOR RECURRENCE AFTER LAPAROSCOPIC REPAIRWhy laparoscopic? Surgeon educationBenefits of lap repair

TAPP requiredLeave existing mesh in situDissect sac and adjacent peritoneumInsert new mesh, overlapping existing mesh Cover new mesh with mobilised peritoneum / sacRECURRENCE POST TEP REPAIR

TEP AFTER RADICAL PROSTATECTOMYScarring from radical prostatectomyOpen repair = good optionIf TEPNo balloonStart laterallySharp + blunt dissection of scar tissueKeep to abdominal wallHernia sac always = freeModify mesh size

TEP POST RADICAL PROSTATECTOMY

Perseverance..breeds success

END