Avoiding Recurrence


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Avoiding Recurrence

  1. 1. SAGES Presenter Disclosure Slide George S. Ferzli, M.D., F.A.C.S. Nothing To Disclose
  2. 2. Avoiding Recurrences George S. Ferzli M.D., F.A.C.S. Chairman, Department of Surgery Lutheran Medical Center-Brooklyn, N.Y. Professor, Department of Surgery S.U.N.Y-Downstate Medical Center-Brooklyn, N.Y. LUTHERAN MEDICAL CENTER
  3. 3. Hernia Recurrence Patient Factors Surgeon Factors Technical Factors What Causes Recurrence? Anesthetic Selection Mesh Selection Choice of Operation Lack of Experience Age Modifiable Risk Factors Genetic Predisposition Gilbert,A.I., Young,J., Graham, M.F. Presented at Suvretta Meeting, 2006.
  4. 4. Should all patients be treated the same? <ul><li>52 year old male, obese, smoker with a large, recurrent inguinal hernia. </li></ul><ul><li>22 year old female, thin, non-smoker with a small, primary inguinal hernia. </li></ul>
  5. 5. Role of the Patient in Recurrence <ul><li>HEAD Score : </li></ul><ul><li>Hernia of the Adult </li></ul><ul><li>Disease Score </li></ul><ul><ul><li>Attempt to individualize treatment based on 8 factors. </li></ul></ul><ul><ul><li>Courtesy of Dr. Christian Peiper </li></ul></ul>
  6. 6. Role of the Patient in Recurrence <ul><li>Peiper et al . </li></ul><ul><ul><li>Retrospective review of 293 Shouldice repairs </li></ul></ul><ul><ul><li>Overall recurrence rate  11.1% </li></ul></ul><ul><ul><li>Recurrence rate in primary hernias  7.7% </li></ul></ul><ul><ul><li>Recurrence rate HEAD score  15  2.7% </li></ul></ul><ul><li>Presented at Suvretta meeting, 2006. </li></ul>
  7. 7. Tailored Approach to Hernia Repair 405 Patients HEAD Score  15 HEAD Score < 15 Mesh Repair Lichtenstein/TIPP in Primary Hernias TAPP in Bilateral/Recurrent Hernias Shouldice Repair 2.65 % Recurrence Rate at 12 months Peiper et al. Presented at Suvretta meeting, 2006.
  8. 8. Tailored Approach to Hernia Repair <ul><li>HEAD score does not take obesity into account. </li></ul><ul><ul><li>? Develop modified HEAD score for Americans. </li></ul></ul><ul><li>Pre-operative collagen testing? </li></ul><ul><ul><li>Abnormal collagen metabolism in primary inguinal and incisional hernia formation 1 . </li></ul></ul><ul><ul><li>Collagen I/III ratio is altered by  Type III collagen and  Type I collagen 2 . </li></ul></ul><ul><ul><li>Would pre-op skin testing lead us to the “right” repair and thus reduce recurrence? </li></ul></ul><ul><ul><li>Can we modify collagen ratio with pre-op medications? </li></ul></ul><ul><li>1 Friedman,D.W.,Boyd,C.D.,Norton,P.,Greco,R.S.,Boyorsky,A.H.,Mackenzie,J.W.,Deak,S.B. Increases in type III collagen gene expression and protein synthesis in patients with inguinal hernias. Ann Surg. 1993 Dec;218(6):754-60. </li></ul><ul><li>2 Rosch, R., Klinge,U.,Si,Z.,Junge, K.,Klosterhalfen,B., Schumpelick, V. A role for the collagen I/III and MMP-1/-13 genes in primary inguinal hernia? BMC Med Genet. 2002;3:2. </li></ul>
  9. 9. Role of the Surgeon in Recurrence Does Choice of Operation Affect Recurrence? <ul><li>Choice of Operation </li></ul><ul><ul><li>Open mesh vs. Tissue repair </li></ul></ul><ul><ul><ul><li>Tension free mesh repair provides lower recurrence rate 3 </li></ul></ul></ul><ul><ul><li>Laparoscopic vs. Open </li></ul></ul><ul><ul><ul><li>Examination of literature demonstrates no difference in recurrence rates when comparing Lap to Open tension free mesh repairs 4 . </li></ul></ul></ul><ul><ul><ul><li>VA study supports open over laparoscopic repair for primary hernias 5 . </li></ul></ul></ul><ul><ul><li>TAPP vs. TEP </li></ul></ul><ul><ul><ul><li>Recent Meta-analysis gives no indication that one technique is superior 6 . </li></ul></ul></ul><ul><li>3 Collaboration, EH. Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg. 2000 Jul;87(7):854-9. </li></ul><ul><li>4 Collaboration, EH. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg. 2000 Jul;87(7):860-7. </li></ul><ul><li>5 Neumeyer, l., Giobbie-Hurder, A. et al.Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004 Apr 29;350(18):1819-27. </li></ul><ul><li>6 McCormack, K.,Wake, B.L.,Fraser,C.,Vale,C.,Perez,J.,Grant,A. Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review. Hernia. 2005 May;9(2):109-14. </li></ul>
  10. 10. Role of the Surgeon in Recurrence <ul><li>Learning Curve in Laparoscopic Hernia Repair </li></ul><ul><ul><li>The more you do the better you are. </li></ul></ul><ul><ul><li>How many cases required to be proficient? </li></ul></ul><ul><ul><ul><li>30-50 cases as suggested by Davis et al 7 </li></ul></ul></ul><ul><ul><ul><li>250 cases as suggested by Neumayer et al 8 </li></ul></ul></ul><ul><ul><li>Difficult to apply magic number concept to individual surgeons. </li></ul></ul><ul><li>7 Davis, CJ., Arregui, ME. Laparoscopic repair for groin hernias.Surg Clin North Am. 2003 Oct;83(5):1141-61. </li></ul><ul><li>8 Neumeyer, l., Giobbie-Hurder, A. et al.Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004 Apr 29;350(18):1819-27 </li></ul>
  11. 11. Role of the Surgeon in Recurrence <ul><li>Answer to prolonged learning curve? </li></ul><ul><ul><li>Surgeon Education 10,11,12 </li></ul></ul><ul><ul><ul><li>Simulators? </li></ul></ul></ul><ul><ul><ul><li>Mastery of open preperitoneal repair first? </li></ul></ul></ul><ul><ul><ul><li>Cadaveric/Animal based courses? </li></ul></ul></ul><ul><ul><ul><li>Intensive, prolonged mentoring by experienced surgeon? </li></ul></ul></ul><ul><ul><li>Referral of patients to high volume specialty centers? 9 </li></ul></ul><ul><li>9 Fong, Yuman MD; Gonen, Mithat PhD; Rubin, David MS; Radzyner, Mark MBA, JD; Brennan, Murray F. MD Long-Term Survival Is Superior After Resection for Cancer in High-Volume Centers. Annals of Surgery. 242(4):540-547, October 2005. </li></ul><ul><li>10 Sherman, V., Feldman, L.S., Stanbridge, D., Kazmi, R., Fried, G.M.Assessing the learning curve for the acquisition of laparoscopic skills on a virtual reality simulator. Surg Endosc. 2005 May;19(5):678-82. </li></ul><ul><li>11 Lal, P., Kajla, R.K., Chander, J., Ramteke, V.K . Laparoscopic total extraperitoneal (TEP) inguinal hernia repair: overcoming the learning curve. Surg Endosc. 2004 Apr;18(4):642-5. </li></ul><ul><li>12 Broin, E.O.,Horner, C., Mealy, K., Kerin, M.J., Gillen, P., O Brien, M., Tanner, W.A. Meralgia paraesthetica following laparoscopic inguinal hernia repair. An anatomical analysis. Surg Endosc. 1995 Jan;9(1):76-8. </li></ul>
  12. 12. Local, Regional, or General Anesthesia ? <ul><li>• 13 Nordin, P.,Zetterstrom,H.,Gunarsson, U.,Nilsson,E. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet. 2003 Sept 13;362(9387):853-8. </li></ul>
  13. 13. Local, Regional, or General Anesthesia ? Mortality and Anesthetic Choice (103 710 Hernias) <ul><li>Mortality risk is defined as ratio between observed and expected death rates considering age and sex of background population in Sweden (SMR). </li></ul><ul><li>Nordin,P., Nilsson E. </li></ul>1,95 – 2,64 2,27 76,07 173 57,439 General anaesthesia 1,06 – 1,59 1,31 75,69 99 29,843 Regional anaesthesia 0,39 - 0,99 0,64 31,28 20 16,428 Local anaesthesia 95% CI SMR* Expected number of deaths Observed number of deaths Number of operations
  14. 14. Local, Regional, or General Anesthesia ? Choice of anaesthesia and relative risk (RR) * for reoperation following 107 838 primary and recurrent hernia operations <ul><li>* Multivariate analysis according to Cox’s proportional hazards model. </li></ul><ul><li>14 Nordin,P.,Haapaniemis, S.,van der Linden, W.,Nilsson,E. Choice of anesthesia and risk of reoperation for recurrence in groin hernia repair. Ann Surg. 2004 Jul;240(1):187-92. </li></ul>
  15. 15. Integrity of Mesh <ul><li>Cases of mesh rupture in ventral hernia repair: </li></ul><ul><ul><li>Langer et al.  Marlex rupture 1 case 2001 15 </li></ul></ul><ul><ul><li>Spital et al.  Marlex rupture 2 cases 2003 * </li></ul></ul><ul><ul><li>Conze et al.  Vypro rupture 2 cases 2006 * </li></ul></ul><ul><ul><li>Flament et al .  Vypro rupture 2 cases 2006 * </li></ul></ul><ul><li>15 Langer, C., Neufang,T.,Kley, C.,Liersch, T.,Becker,H., Central mesh recurrence after incisional hernia repair with Marlex--are the meshes strong enough? Hernia. 2001 Sep;5(3):164-7. </li></ul><ul><li>* Personal communication </li></ul>
  16. 16. Biocompatibility of Meshes Comparison of macroscopic and histopathological findings (mean ± SD) <ul><li>-Courtesy of Hanover Hospital </li></ul>
  17. 17. Choice of Mesh “The ideal mesh” (TEP/TAP) <ul><li>Weight per m 2  </li></ul><ul><li>Size </li></ul><ul><li>Rigidity  </li></ul><ul><li>Stability  </li></ul><ul><li>Pore size  </li></ul><ul><li>Monofilament </li></ul><ul><li>Courtesy of Hanover Hospital </li></ul><ul><li>< 35 g </li></ul><ul><li> 10 X 15 cm </li></ul><ul><li>Endoscopic handling </li></ul><ul><li>150mmHg= ~16 N/cm </li></ul><ul><li> 1mm </li></ul><ul><li> multifilament </li></ul>
  18. 18. Novel Mesh Ideas <ul><li>Biologic Meshes </li></ul><ul><ul><li>Alloderm  </li></ul></ul><ul><ul><ul><li>Human dermal matrix </li></ul></ul></ul><ul><ul><ul><li>May have use as adjunct to abdominal wall reconstruction 16 . </li></ul></ul></ul><ul><ul><li>Surgisis  </li></ul></ul><ul><ul><ul><li>Porcine small intestinal submucosa </li></ul></ul></ul><ul><ul><ul><li>Promising early results in treatment of hernia in contaminated field 17 . </li></ul></ul></ul><ul><li>Medication impregnated mesh </li></ul><ul><ul><li>Gold/Gold-pallidum impregnated mesh </li></ul></ul><ul><ul><ul><li>Mesh infection prevented in mouse S. epidermidis model 18 </li></ul></ul></ul><ul><ul><li>Antibiotic impregnated mesh </li></ul></ul><ul><ul><ul><li>Gore Dual- Mesh  PLUS impregnated with silver carbonate and chlorhexidine diacetate </li></ul></ul></ul><ul><li>16 Scott,B.G.,Welsh,F.J.,Pham,H.Q.,Carrick,M.M.,Liscum,K.R.Granchi,T.S.,Well,M.J.,Mattox,K.L.,Hirschberg, Early aggressive closure of the open abdomen. J Trauma. 2006 Jan;60(1):17-22. 17 Franklin, M.E.,Gonzalez, J.J.,Glass, J.L., Use of porcine small intestinal submucosa as a prosthetic device for laparoscopic repair of hernias in contaminated fields: 2-year follow-up. Hernia. 2004 Aug;8(3):186-9 </li></ul><ul><li>18 Saygun, O.,Agalar, C., Aydinuraz, K.,Agalar,F.,Daphen,C.,Saygun,M.,Ceken,S.,Akkus,A.,Denkbas,E.B., Gold and gold-palladium coated polypropylene grafts in a S. epidermidis wound infection model. J Surg Res. 2006 Mar;131(1):73-9. </li></ul>
  19. 19. <ul><li>19 Lowham A.S, Filipi,C. J, Fitzgibbons R.J, Stoppa, R. Wantz G., Felix,E. Crafton, W.B . Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic. Ann Surg. 1997 Apr;225(4):422-31. </li></ul><ul><li>20 Phillips, E.H., Rosenthal, R., Fallas, M., Carroll, B., Arregui, M., Corbitt, J., Fitzgibbons, R., Seid,A.,Schultz L.,Toy,F.Reasons for early recurrence following laparoscopic hernioplasty. Surg Endosc. 1995 Feb;9(2):140-4. </li></ul><ul><li>21 Felix, E.L. A unified approach to recurrent laparoscopic hernia repairs. Surg Endosc. 2001 Sep;15(9):969-71. </li></ul><ul><li>22 Kaafarami,H.M.,Itani,K.M.,Giobbie-Hurder,A.,Gleysteen, J.J.,McCarthy,M.,Gibbs,J.,Neumayer,L. Does surgeon frustration and satisfaction with the operation predict outcomes of open or laparoscopic inguinal hernia repair? J Am Coll Surg. 2005 May;200(5):677-83. </li></ul>Failure to Expose Entire Myopectineal Orifice 19 Missed Hernia 20 Surgeon Frustration 22 Missed Lipoma 21 Role of the Technique in Recurrence Recurrence
  20. 20. 6 Steps 1 2 3 4 5 6
  21. 21. Fundamentals <ul><li>direct hernia medial to epigastric vessels - cannot see Cooper’s ligament or femoral canal </li></ul><ul><li>indirect hernia lateral to epigastric vessels - cannot see vas deferens </li></ul><ul><li>never a hernia between vas and epigastric vessels </li></ul>
  22. 22. Indirect
  23. 23. Indirect
  24. 24. Direct
  25. 25. Lipoma of the cord <ul><li>sac rotated medially </li></ul>
  26. 26. Anatomy
  27. 27. <ul><li>23 Fischer, E., Wantz, G.,Traditional Preperitoneal Approach to Inguinal Hernias. Semin Laparosc Surg. 1994 Jun;1(2):86-97. </li></ul><ul><li>24 Felix, E.,Scott,S.,Crafton B., Geis, P.,Dunacn, T, Sewell, R.,McKernan, B., Causes of recurrence after laparoscopic hernioplasty. A multicenter study. Surg Endosc. 1998 Mar;12(3):226-31 </li></ul><ul><li>25 Moreno-Egea, A, Torralba Martinez, J.A., Morales Cuenca, G. Aguayo Albasini, J.L. Randomized clinical trial of fixation vs nonfixation of mesh in total extraperitoneal inguinal hernioplasty. Arch Surg 2004Dec;139(12):1376-9. </li></ul><ul><li>26 Fawole,A.S.,Chaparala,R.P.,Ambrose,N.S., Fate of the inguinal hernia following removal of infected prosthetic mesh. Hernia. 2006 Mar;10(1):58-61. </li></ul>Improper Utilization of the Mesh Wrong Mesh Configuration 23 Mesh Infection 26 Inadequate Fixation 25 Indequate Mesh Size 20 Role of the Technique in Recurrence Creation of Keyhole 24 Recurrence
  28. 28. Mesh placement
  29. 29. “ Other Causes of Recurrence?” <ul><li>Hematoma/Seroma? </li></ul><ul><ul><li>Lau et al . describe a 7.2% seroma formation rate in TEP. Seromas resolved spontaneously at a mean of 2.4 months and did not influence recurrence rate 27 . </li></ul></ul><ul><li>Mesh movement? </li></ul><ul><ul><li>Choy et al . performed TEP with 15 X 15 cm mesh followed by desufflation, repetitive hip flexion and re-examination of the mesh. In no case did the mesh migrate 28 . </li></ul></ul><ul><li>Early strenuous activity? </li></ul><ul><ul><li>Bay-Nielson et al . demonstrated no difference in early recurrence rate between patients advised to take a short convalescence ( 1 day) versus a long convalescence 29 . </li></ul></ul><ul><ul><li>Let pain be the guide to resumption of activity? </li></ul></ul><ul><li>27 Lau, H.,Lee,F. Seroma following endoscopic extraperitoneal inguinal hernioplasty. Surg Endosc. 2003 Nov;17(11):1773-7. </li></ul><ul><li>28 Choy, C., Shapiro, K.,Patel, S.,Graham,A.,Ferzli,G., Investigating a possible cause of mesh migration during totally extraperitoneal (TEP) repair. Surg Endosc. 2004 Mar;18(3):523-5. </li></ul><ul><li>29 Bay-Nielson,M.,Thomsen,H.,Andersen,F.H.,Bendix, J.H.,Sorensen, O.K.,Skovgaard,N.,Kehlet,H. Convalescence after inguinal herniorrhaphy. Br J Surg. 2004 Mar;91(3):362-7. </li></ul>
  30. 30. Conclusion <ul><li>Hernia recurrence is multifactorial. </li></ul><ul><li>A single, best approach to hernia repair does not exist. </li></ul><ul><li>A tailored approach based on clinical data (HEAD score, skin biopsy) may be more appropriate. </li></ul><ul><li>Regardless of technique chosen, thorough knowledge of the anatomy is critical to success. </li></ul>