Laparoscopic vs Open Inguinal Hernia repair

1. ANDREW S. WRIGHT MD
DIRECTOR, UW MEDICINE HERNIA
CENTER
TWITTER: @ANDREWSWRIGHT
EMAIL: AWRIGHT2@UW.EDU
Open vs. MIS Inguinal Hernia

4. Types of hernia repair
 Open Tissue
 High Ligation
 Bassini
 McVay
 Halstead
 Shouldice
 Desarda
 Marcy
 Open Anterior Repair
 Lichtenstein
 Modified Lichtenstein
 Open Posterior Repair
 Plug
 OnStep
 Stoppa
 Open Hybrid repair
 Plug/patch
 PHS/UHS
 Lap Repair
 TEP
 TAPP
 rTAPP
 eTEP
 IPOM

5. Types of hernia repair
 Open Tissue
 High Ligation
 Bassini
 McVay
 Halstead
 Shouldice
 Desarda
 Marcy
 Open Anterior Repair
 Lichtenstein
 Modified Lichtenstein
 Open Posterior Repair
 Plug
 OnStep
 Stoppa
 Open Hybrid repair
 Plug/patch
 PHS/UHS
 Lap Repair
 TEP
 TAPP
 rTAPP
 eTEP
 IPOM
Lichtenstein Repair is Gold Standard

6.  Not all hernias are the same!

7.  Not all hernias are the same!

8. Hernia Outcomes that Matter

9. Hernia Outcomes that Matter
 Recurrence
 2-5%
 Highly dependent on Surgeon experience and volume

10. Outcomes that matter - Pain
 Chronic Pain
 8-20% Mesh sensation
 1-2% Daily pain
 0.1% Disabling

11. Outcomes that matter - Pain
 Chronic Pain
 8-20% Mesh sensation
 1-2% Daily pain
 0.1% Disabling
 770,000 hernia repairs annually

12. Outcomes that matter - Pain
 Chronic Pain
 8-20% Mesh sensation
 1-2% Daily pain
 0.1% Disabling
 770,000 hernia repairs annually
 77,000 patients with disabling pain

13. Outcomes that matter - Pain

14. Secondary Outcomes
 Cost
 OR time
 Return to work
 Cosmesis

15. Option: Watchful Waiting
 Acute event 1.8/1,000 patient years
 No limitation on exercise or activity

16. Option: Watchful Waiting
 Acute event 1.8/1,000 patient years
 No limitation on exercise or activity
 Crossover 76% at 7 years

17. Tissue Repair: why?
 20% Google searches for health information

18. Tissue Repair: why?
 20% Google searches for health information

19. Tissue Repair: why?
 20% Google searches for health information

20. Option 1: Tissue Repair
 Shouldice

21.  Shouldice
 Highly selected patient
 Technical and operator dependent

22.  Shouldice
 Cochrane review 2012 Shouldice vs. other open tissue repairs

23. Open Mesh (Lichtenstein) Repair
 Advantages
 Quick
 Reproducible
 Local anesthetic
 Low recurrence
 Disadvantages
 Foreign Body
 Proximity to nerves

24.  Shouldice
 Cochrane review 2012 Shouldice vs. mesh repairs

25.  Shouldice
 Cochrane review 2012 Shouldice vs. mesh repairs
No decrease in chronic pain in Shouldice vs.
Lichtenstein

26. Types of hernia repair
 Open Tissue
 High Ligation
 Bassini
 McVay
 Halstead
 Shouldice
 Desarda
 Marcy
 Open Anterior Repair
 Lichtenstein
 Modified Lichtenstein
 Open Posterior Repair
 Plug
 OnStep
 Stoppa
 Open Hybrid repair
 Plug/patch
 PHS/UHS
 Lap Repair
 TEP
 TAPP
 rTAPP
 eTEP
 IPOM
Lichtenstein Repair is Gold Standard

27. Lichtenstein
 Key step!
 Identification and preservation of nerves

28. Lichtenstein
 Key step!
 Identification and preservation of nerves
1/3 Reduction in pain at 3 months with intra-op
Marcaine nerve block

29. Lichtenstein modifications
 no-suture glue technique (TIMELI trial)
 Significant reduction in disabling pain
 No difference in recurrence

30. ProGrip

31. ProGrip mesh

32. Progrip
 Potential benefits
 Reduced risk of nerve injury
 Faster OR time
 Potential disadvantages
 Increased cost
 Increased inflammatory reaction
 Several single center RCTs
 Underpowered
 No difference in chronic pain or recurrence
 Possible increase in foreign body sensation

33. Options: Open Preperitoneal Groin
 Mesh Plug
 PHS – Prolene Hernia System
 UHS
 ONSTEP
 Insightra
 Kugel
 TREPP (transrectus preperitoneal)

34. Outcomes of open preperitoneal repair
 Most proprietary systems lacking data
 3 year outcomes no different than standard
Lichtenstein

35. My Recs
 Open preperitoneal repairs burn bridges
 Plug migration
 Meshoma
 No evidence that any proprietary system better than
Lichtenstein

37. Option: Open Preperitoneal (Midline)
 Stoppa Repair – Maximally invasive

38. Stoppa Repair

39. MIS Inguinal Hernia Repair

40. Laparoscopic Repair
 Advantages
 Less short term and chronic pain, Faster Recovery
 Address bilateral hernias, femoral hernias
 Avoid ilioinguinal and iliohypogastric nerves

41. Laparoscopic Repair
 Disadvantages
 Technically more challenging
 Better outcomes in RCTs and in expert hands

42. Lap vs Open: What Does the Data Say?
 Neumayer L et al. NEJM 2004: 350(18); 1819-1827.
 Multicenter randomized trial, VA
 1983 patients
 Two year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%

43. Lap vs Open: What Does the Data Say?
 Neumayer L et al. NEJM 2004: 350(18); 1819-1827.
 Multicenter randomized trial, VA
 1983 patients
 Two year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%
 Concluded: primary unilateral hernias should be repaired
with OIHR

44. Lap vs Open: What Does the Data Say?
 Neumayer L et al. NEJM 2004: 350(18); 1819-1827.
 Multicenter randomized trial, VA
 1983 patients
 Two year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%
 Concluded: primary unilateral hernias should be repaired
with OIHR
 Critique:
 Average age of pts was high, health related QOL low c/w general
population
 VA Population
 Surgeon inexperience/learning curve
 Those with >250 cases had recurrence rate <5% in LIHR

45. Lap vs Open Inguinal Hernia
 Kouhia STH et al. Ann Surg 2009; 249(3): 384-387
 90 patients randomized
 6.4% recurrence in OIHR vs. 0% for TEP (ns)
 Higher incidence of chronic pain in OIHR group
 TEP group with less analgesic requirement and shorter return
to work

46. META-ANALYSIS
RANDOMIZED CLINICAL TRIALS
 29 trials
 5588 patients (3017 laparoscopic)
 6 outcomes evaluated
 Operating time, Time to discharge, Return to normal activity, Return
to work, Postoperative complications, Recurrence rate
 Favoring Lap:
 postop complications, return to normal activity, return to work, time to discharge
 Favoring Open:
 OR time (15min)
 No Difference in Recurrence
Memon, MA et al. Br J Surg 2003: 01: 1479-1492
COMPARING OPEN AND LAPAROSCOPIC
INGUINAL HERNIA REPAIR

47. Hernia Outcomes that Matter
 Recurrence
 2-5%
 Highly dependent on Surgeon experience and volume

48. Lap vs. Open
Lap
 Less Pain
 Faster Recovery
 Bilateral and Recurrent
 More operator
dependant
Open
 Easier to learn
 Reproducible
 Good results
Make a choice, don’t reserve lap for bilaterals and recurrence or you will never
overcome the learning curve

50. Questions?
awright2@uw.edu
Twitter: @andrewswright