1. LAPAROSCOPIC INGUINAL HERNIA REPAIR George Ferzli, MD, FACS Professor of Surgery, SUNY Where are we in 2009? 2009?

2. These are the questions we have already answered:

17. 1. What is the role of TAPP/TEP after TAPP/TEP? Questions remaining in 2009

20. TAPP after präperit.mesh-rep. n = 135* op-time [median,min.] 75 morbidity 8,1 % reop.-rate 2,2 % rec.-rate 0,74 % return to work [med,d] 17 age [median] 59 [29-90] BMI [median] 25 Marienhospital Stuttgart IV / 93 – XII / 05 results Laparoscopic Hernia Repair (TAPP) *own recurrences n=73 from outside n=62

21. n (Prof)* 1-45 (1-20)* 46-90 (21-40)* 91-135 (41-56)* (6/93-12/98) ( 12/98-02/02) ( 2/02-11/05) op-time [median,min.] ( Prof.)* 82,5 (87,5)* 71 (85)* 77 (57,5)* morbidity 14% 8 % 2% reop.-rate 2,2% 2,2% 2,2 % rec.-rate - - 2,2 % return to work [med.,d] 18 17 17 Results (n=135) [“learning curve”] TAPP after preperitoneal mesh repair Marienhospital Stuttgart IV / 93 – XII / 05

22. 2. Do we have an answer for groin pain after hernia repair?

23. Nerves prone to injury at herniorraphy: anterior and posterior

24. Groin pain incidence * Groin pain or discomfort lasting more than 3 months after groin hernia repair. Intern. Assn. for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain . 1986; 3 (suppl): 1–226. Author # of Pts Pain * Pain Severe Outcome of Pain A. S. Poobalan 2001 226 30% > 3 mo Morten Bay-Nielsen 2001 1166 28.7% > year 3% S. Kumar 2002 454 30% >21 mo C. A. Courtney 2002 4062 > 3 mo 3% > 2.5 yrs 71% have pain Severe in 22% Mild in 45% Marcello Picchio 2004 593 25% > 1 yr 6%>1 yr A. M. Grant 2004 928 9.7%>1 yr 1.8% > 5 yrs Jrg Kninger 2004 208 36% (Shouldice) 31% (Lichtenstein) 15% (TAPP) > 52 mo Ulf Fränneby 2006 2456 31% >24 to 36 mo Sergio Alfieri 2006 973 9.7% > 6 mo 2.1 %> 6 mo Mild 4.1% > 1yr Severe 0.5% > 1yr E. K. Aasvang 2006 210 34.3% >1year Less pain 75.8% Same pain 16.7% More severe 7.5% > 6.5 years

25. Quality of life Author Pts Pain affects the quality of life Morten Bay-Nielsen 2001 1166 16.6% S Kumar 2002 454 18.1% Jrg Kninger 2004 208 14% (Shouldice) 13% (Lichtenstein) 2.4% (TAPP) Ulf Fränneby 2006 2456 6% EK Aasvang 2006 210 Nb 24.8% 6% after 6.5 years Sergio Alfieri 2006 973 11.3% to 14.2%

26. Causes and risk factors of groin pain Anatomical Variation Innervation symmetry - 40.6% Normal distribution - 20.3% “ Normal” anatomic pattern - 56.3% Mesh repair No clear correlation between use of mesh and chronic pain Age Studies disagree on correlation between older age and post-herniorrhaphy pain Pre-operative pain Pain associated with hernia before repair is associated with post-operative pain BMI No correlation found between elevated BMI and post-operative pain Post-operative complications Postoperative complications linked to an increased risk for long term pain Recurrent hernia Day case surgery Open versus laparoscopic Recurrence associated with recurrent pain The probability of developing chronic pain is 2.5 times higher in day-case patients, controlling for age Open repair strongly correlated with post-operative pain compared to laparoscopic repair

30. Surgical management: neurectomy Author # of Pts Excellent relief Partial relief Poor result Lyon 1942 6 83% Magee 1945 5 100% Starling 1987 30 83% Cathy H Lee 2000 54 68% II 78% IH 83% GF 50% 10% 11% 17% 25% Amid PK 2004 225 80% 15% 5% James A. Madura 2005 Aasvang 2009 100 21 72% 62% 25% 24% (no change) 3% 14%

31. Surgical management: mesh removal, neurectomy and hernia repair The laparoscopic approach: Diagnostic Definitive hernia repair in unaltered tissues Anterior approach: Removal of the offending foreign body Appropriate nerve resection 21 pts Licht (n=12), McVay (n=1), plug / patch (n=2), Shouldice (n=1), Lap (n=6) 6 weeks F/U, 20/21 pts were significantly improved (3 pts had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. ) Keller JE, Stefanidiis D, Dolce CJ, Ianitti DA, Kercher KW, Heniford TB. Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair. 2008 Amer Surg 74: 695-701

32. Surgical management: prophylactic neurectomy Author # of Pts Pain (Neurectomy vs Non-neurectomy) Paresthesia Ravichandran 2000 20 bilateral 0% vs 5% 10% vs 0% Marcello Picchio 2004 408 vs 405 Mild: 21% vs 18% Moderate: 3% vs 4% Severe: 3% vs 2% p 0.55 Numbness 4% vs 6% p 0.39 Loss of touch sensation 11% vs 4% p 0.002 Loss of pain sensation 9% vs 8% p 0.89 DE Tsakayannis 2004 191 0 Numbness 6.28% Sensory Loss 1.04% George W Dittrick 2004 66 vs 24 6 mos.3% vs 26% (p 0.001) 1 yr 3% vs 25% (p 0.003) 18% vs. 4% (p 0.10) 13% vs. 5% (p 0.32) Wilfred Lik-Man Mui 2006 50 vs 50 8% vs 28.6% (p 0.008) 42 vs 42.9 (P 0.931)

35. results [Marienhospital Stuttgart Apr’ 93 – Dez’ 07] *eigene Rezidive: n=92 extern vorop: n=70 PH (without preop.) last 2000 40 1,7% 0,3% 0,1% 10 50 [17-100] 25 PH n=13136 40 2,8% 0,4% 0,7% 14 60 [17-97] 25 scrotal hernia n=807 60 4,4% 0,85% 2,3% 17 61(18-97) 25 post. repair n=162* 75 7,0% 3,8% 0,6% 17 59 [29-90] 25 n op-time [med.,min.] morbidity reop.-rate rec.-rate out of work [med.,days age [Median] BMI [Median] TAPP Marienhospital Stuttgart, 3 / 1993 – 12 / 2007

49. Combined laparoscopic and open treatment