why lap inguinal hernia repair is progressing at slow momentum ? our experience
DESCRIPTION
laparoscopicTAPP vs open Lichtenstein mesh inguinal hernia repairTRANSCRIPT
WHY LAP INGUINAL HERNIA REPAIR IS PROGRESSING AT SLOW MOMENTUM ? OUR EXPERIENCE
Authors:
DR. AYMEN KHAN
DR. HRIDAY HALOI
DR. D K CHOUDHURY
DR. H K BHATTACHARYA
Department of Surgery
Gauhati Medical College
After introduction of lap cholecystectomy laparoscopy continues to explore in different advanced surgical field .
Lap inguinal hernia repair is considered to be a widely accepted procedure all over the world at present
But it seems that the procedure is not getting the fast momentum like laparoscopic cholecystectomy in common in our society.
AIMS AND OBJECTIVES To evaluate possible factors for which the
procedure is less commonly done by even highly skilled lap surgeon in spite of large volume of inguinal hernia cases in our society
To obtain views of the patients presenting with inguinal hernia towards laparoscopic repair
To share our experience while doing both lap inguinal hernia repair and open repair
MATERIALS AND METHODS
We studied 60 cases of inguinal hernia attending our OPD in last six months
Complicated hernia excluded from study
Hernia in pediatric age group also excluded
Hernia with morbid condition like cardiac cause and above 70 years excluded from the study
All 60 cases of the study were asked the following question
Do you know that there are two methods of operation for inguinal hernia, which are open operation and laparoscopic repair ??
56 (93.3%) cases of total 60 cases of inguinal hernia of our series were un aware of the lap hernia procedure
4(6.7%) Patients were aware of the lap hernia procedure
Only 4(6.7%) cases out of 60 cases attended our OPD for lap hernia repair
Rest 56 cases out of 60 cases attend to get operated to get rid of their hernia problem
Following informations were given to the patients
You can be operated either by laparoscopy or by open technique
In laparoscopy few holes will be made and in open , incision will be made
You will need to undergo general anaesthesia in laparoscopy
Spinal anesthesia will be sufficient for most of the cases in open repair
Both the cases you need to be hospitalized for one day
56 cases raised the following question Which procedure is better according
to the surgeon Accordingly the patients will decide the
type of procedure to undergo
Patients were informed the following No favouritism was given to any procedure Both the technique has their own pro and
cones Laparoscopy is cosmetically better Post operative pain is said to be less than open Regarding recurrence both the technique
carries almost same recurrence Cost will be high if tacker wants to be used But we can cut down cost by suturing and
avoiding tacker
38(63.3%) cases of 56 cases refused to undergo laparoscopic hernia repair after getting proper information from us as NICE guideline
16(26.6%) cases refused to undergo the procedure initially because of high cost but agreed to undergo lap by suturing technique
Two patients who were unaware of the procedure were convinced to undergo lap repair with tacker
Intra Operative Observation
All the patients opted for laparoscopy were done by TAPP procedure
Right sided inguinal hernia repair comparatively have easier ergonomics than left side for us during the surgery
Duration of surgery was more in initial learning curve up to 2 and half hours to three hours where tacker was avoided and repair was done by suturing
Later duration was reduced to 1 and half hours to 2 hours We found direct hernia is easier to dissect than indirect
hernia Careful dissection required specially during paritalisation
to prevent vascular injury
Post Operative Observation
Post operative pain was 50% less in lap procedure than open
Both group were kept hospitalized for one day
Oral feeding started after 24 hours in both groups
Both the groups were mobilised next day
COMPLICATIONS LAP HERNIA REPAIR
OPEN REPAIR
WOUND INFECTION I 2
SEROMA 1 NIL
HYDROCELE NIL NIL
INDURATION OF CHORD AND TETIS
NIL 7
ATYPICAL MYCOBACTERIA
INFECTION
1 0
MESHNEURALGIA NIL 3
PARASTHESIA OF GROIN NIL 1
LAP HERNIA OPEN HERNIASKILL OF LAPAROSCOPY NEEDS HIGH AND TO BE
LEARNED BY SURGEON BY HIMSELF BY
PRACTISCE WITH PATIENCE
NORMAL
COST HIGH NORMAL
LIFE THREATINING COMPLICATIONS
CHANCES ARE HIGH IF CARELESS
VERY RARE
COST REDUCTION ATTEMPT
SUTURING IS NOT ENJOYED BECAUSE OF POOR ERGONOMICS OF
SUTURING
NOT REQUIRED
MOTIVATION OF PATIENTS
DEPENDS UPON SURGEONS’
CONFIDENCE
NOT REQUIRED
SUMMARY
Post operative pain was less in lap hernia repair group than in the open group
Better cosmesis in lap hernia group than open group
No significance difference of complications observed in either group
Cost is high in lap hernia because of use of large size mesh and tacker
If suturing is done in stead of tacker to curtail cost it requires extra time and strain to the surgeon
In terms of recurrence the rate is same in both open and lap cases .
There is no difference in recurrence in both technique in reported large studies also
Open repair can be done either in spinal or local anesthesia
CONCLUSION Cost of the procedure is much higher than the open
technique which is not usually accepted by average patients volume in first look
Lap hernia repair cannot claim ,at present moment, any boosting results in terms of recurrences, complication, return to work in comparison to open repair except in terms of cosmesis and post operative pain .
Lap hernia repair requires complex and careful dissection in vital area as opposed to very simple open lichtenstein repair so learning curve of the surgeon is high to acquire skill
Motivation of patients for lap hernia will mostly depend on surgeon and his credibility to deliver the similar result like open hernia without compromising the overall safety of the patients.
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