LAPAROSCOPIC INGUINAL HERNIA REPAIR George Ferzli, MD, FACS Professor of Surgery, SUNY Where are we in 2009? 2009?
These are the questions  we have already  answered:
What are the indications for laparoscopic inguinal hernia repair? <ul><li>Recurrent hernia </li></ul><ul><ul><li>Avoids sc...
Are there contraindications to laparoscopic inguinal hernia repair? <ul><li>Contraindications </li></ul><ul><ul><li>Patien...
How do recurrence rates for open and laparoscopic hernia repair compare? <ul><li>Reference Year Pts/R  Hrns Hernia Tech RR...
What is the role of laparoscopy for treating recurrent inguinal hernia? <ul><li>Less recurrence </li></ul><ul><li>Less pai...
What percentage of a general surgeon’s practice are recurrent hernias? <ul><li>Repair of recurrent hernia is a surrogate f...
Consider - you have to be good at repairing recurrent inguinal hernias <ul><li>Bisgaard  2008 Danish Hernia Database (67,3...
Re-recurrence after TAPP for recurrence  (national and large studies) <ul><li>Reference Year Pts/Hrns PT RT (no. Pts or Hr...
TEP for recurrent inguinal hernia  <ul><li>Reference Year Pts RT RRR  </li></ul><ul><li>Bay-Nielson 2001 78 TEP 1.3%  </li...
Pain score after TAPP for recurrent  inguinal hernia <ul><li>Reference Year Technique No. of Patients Median VAS </li></ul...
Pain score after TEP for inguinal hernia <ul><li>Reference Year Technique No. of Patients Median VAS </li></ul><ul><li>Bri...
Return to regular activity after TAPP for  recurrent inguinal hernia <ul><li>Reference Year Technique Median days to retur...
Return to regular activity after TEP inguinal hernia repair <ul><li>Reference Year Technique Median days to return to work...
<ul><li>Crawford found an incidence of 8% occult femoral hernia at laparoscopic repair,  </li></ul><ul><li>and Felix found...
No missed hernia (femoral hernias) <ul><li>3,980 femoral hernia repairs from Swedish Hernia Register </li></ul><ul><li>1,4...
1. What is the role of TAPP/TEP  after TAPP/TEP? Questions remaining in 2009
<ul><li>Study Primary Repair  Recur. Repair Tech.  Re-recurrence Follow up </li></ul><ul><li>Knook  1999 Various Lap. TAPP...
<ul><li>Study Primary Repair  Recur. Repair Tech.  Re-recurrence Follow up </li></ul><ul><li>Keider  2002 TAPP / TEP  TAPP...
TAPP  after    präperit.mesh-rep.   n = 135*  op-time  [median,min.] 75   morbidity 8,1 % reop.-rate 2,2 % rec.-rate 0,74 ...
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  [med...
2. Do we have an answer for  groin pain after hernia repair?
Nerves prone to injury at herniorraphy:  anterior and posterior
Groin pain incidence *   Groin pain or discomfort lasting more than 3 months after groin hernia repair. Intern. Assn. for ...
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 ...
Causes and risk factors of groin pain Anatomical Variation Innervation symmetry - 40.6% Normal distribution - 20.3% “ Norm...
Types of post-operative groin pain Neuropathic <ul><li>Perineural fibrosis </li></ul><ul><li>Neuroma  </li></ul><ul><li>Ne...
Non-surgical management <ul><li>Non-operative attempts at pain resolution include:  </li></ul><ul><li>Biofeedback </li></u...
<ul><li>Surgical treatment for periosteal reaction or osteitis pubis consists of  </li></ul><ul><li>removing suture materi...
Surgical management: neurectomy Author # of Pts Excellent relief Partial relief Poor result Lyon 1942 6 83% Magee 1945 5 1...
Surgical management: mesh removal, neurectomy and hernia repair The laparoscopic approach:  Diagnostic  Definitive hernia ...
Surgical management:  prophylactic neurectomy Author # of Pts  Pain (Neurectomy vs  Non-neurectomy) Paresthesia Ravichandr...
Surgical management:  nerve identification <ul><li>Identification and preservation of nerves during open inguinal hernia r...
3. What is the role of laparoscopy  in the complex inguinal hernia? <ul><li>Scrotal hernia </li></ul><ul><li>Incarcerated ...
results  [Marienhospital Stuttgart Apr’ 93 – Dez’ 07] *eigene Rezidive:  n=92  extern vorop:  n=70 PH  (without preop.) la...
What Are the Recommendations for Laparoscopic Management of Complex Hernias? Complex Hernia Type Management Recommendation...
Conclusions: <ul><li>Laparoscopic inguinal hernia repair in 2009 is feasible for primary, bilateral and recurrent hernias....
 
References <ul><li>Mahon D, Decadt M, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal preperitoneal...
References <ul><li>Bisgaard T, et al. Re-recurrence after operation for recurrent inguinal hernia. A nationwide 8-year fol...
<ul><li>Felix EL, et al. Laparoscopic repair of recurrent hernia.  Amer J Surg  (1996) 172: 580-584 </li></ul><ul><li>Jarh...
<ul><li>Liebl B, et al. Recurrence after endoscopic transperitoneal hernia repair (TAPP): Causes, reparative techniques, a...
<ul><li>Thill V, Simeons C, Smets D, Ngongang C, da Costa PM. Long-term results of a non-ramdomized prospective mono-centr...
<ul><li>Palanivelu C, Rangarajan M, John SJ. Modified technique of laparoscopic intraperitoneal hernioplasty for irreducib...
<ul><li>Eklund A, Rudberg A, Smedberg C, Enander LK, Leijonmark CE, Osterberg, J. Short-term results of a randomized clini...
 
TAPP after TAPP Hernia re-recurrence <ul><li>Reference Year Pts/R Hrns PT RT (no. Pts or Hrns) RRR   </li></ul><ul><li>Kno...
TAPP and TEP for incarcerated  femoral hernia <ul><li>Incarcerated femoral hernia can be repaired by TAPP or TEP </li></ul...
Combined laparoscopic and open treatment
<ul><li>Study Primary Repair  Recur. Repair Tech.  Re-recurrence Follow up </li></ul><ul><li>Sandbilcher   1996 Anterior (...
<ul><li>Study Primary Repair Recur. Repair Tech. Re-recurrence Follow up </li></ul><ul><li>Beets  1999 Anterior (not  sp.)...
<ul><li>Study Primary Repair  Recur. Repair Techn.  Re-recurrence Follow up </li></ul><ul><li>Bay-Nielson  2001 Various TA...
<ul><li>Study Primary Repair  Recurrent Repair Technique Re-recurrence Follow up </li></ul><ul><li>Mahon  2003 Anterior (n...
<ul><li>Study Primary Repair Recur. Repair Techn. Re-recurrence Follow up   </li></ul><ul><li>Dedemadi  2006 Anterior (not...
<ul><li>Study Primary Repair  Recurrent Repair Technique  Re-recurrence Follow up </li></ul><ul><li>Bisgaard  2008 Lichten...
Post-operative pain after TAPP/TEP for recurrent hernia <ul><li>Study   Repair Technique Median Visual Analog  </li></ul><...
<ul><li>Study Repair Technique Median VAS </li></ul><ul><li>Dedemadi  2006  </li></ul><ul><li>Day of Surgery  TAPP  (n = 2...
Return to work after TAPP/TEP for recurrent hernia <ul><li>Study Median Return to Work / Daily Activities </li></ul><ul><l...
TAPP and TEP for scrotal hernia <ul><li>Laparoscopic repair of the scrotal hernia is controversial and the literature on t...
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Laparoscopic Inguinal Hernia Repair Where Are We in 2009?

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Laparoscopic Inguinal Hernia Repair Where Are We in 2009?

  1. 1. LAPAROSCOPIC INGUINAL HERNIA REPAIR George Ferzli, MD, FACS Professor of Surgery, SUNY Where are we in 2009? 2009?
  2. 2. These are the questions we have already answered:
  3. 3. What are the indications for laparoscopic inguinal hernia repair? <ul><li>Recurrent hernia </li></ul><ul><ul><li>Avoids scar tissue </li></ul></ul><ul><ul><li>Visualizes occult hernia </li></ul></ul><ul><li>Bilateral hernia </li></ul><ul><ul><li>Decreased pain </li></ul></ul><ul><ul><li>Earlier return to work </li></ul></ul><ul><ul><li>No difference in recurrence or complication </li></ul></ul><ul><li>Obese / Athletic patients </li></ul><ul><ul><li>Definitive diagnosis </li></ul></ul><ul><ul><li>Reduced infection in susceptible population </li></ul></ul><ul><ul><li>Gilmore’s groin </li></ul></ul><ul><li>Patients with contralateral injury to vas deferens </li></ul><ul><ul><li>Less chance to injure other vas </li></ul></ul>
  4. 4. Are there contraindications to laparoscopic inguinal hernia repair? <ul><li>Contraindications </li></ul><ul><ul><li>Patients for whom general anesthesia and pneumoperitoneum are risks (cardiac, pulmonary disease) </li></ul></ul><ul><li>Relative Contraindications </li></ul><ul><ul><li>Prior pre-peritoneal surgery (prostate, hernia, vascular, kidney transplant) </li></ul></ul><ul><ul><li>Prior laparotomy </li></ul></ul><ul><ul><li>Ascites </li></ul></ul><ul><ul><li>Strangulated hernia </li></ul></ul><ul><ul><li>Giant scrotal hernia </li></ul></ul><ul><ul><li>Anticipated bleeding (patients on anti-coagulation) </li></ul></ul>
  5. 5. How do recurrence rates for open and laparoscopic hernia repair compare? <ul><li>Reference Year Pts/R Hrns Hernia Tech RR </li></ul><ul><li>Bay-Nielson 2001 547 Lap 1.6% </li></ul><ul><li> 9,982 Licht 1.0% </li></ul><ul><li> 4,373 Muscle repair 2.7% </li></ul><ul><li>EU Hernia 2002 1,643 Lap 2.2% </li></ul><ul><li>Trialist Collab 1,612 Open 1.7% </li></ul><ul><li>Neumayer 2004 862 Lap 10.1% </li></ul><ul><li> 834 Open 4.9% </li></ul><ul><li>“ Highly experienced” Lap <5% </li></ul><ul><li>“ Less than 250” Lap >10% </li></ul><ul><li>No difference in rate of recurrence between laparoscopic and open </li></ul><ul><li>procedures for primary hernia repair. </li></ul>
  6. 6. What is the role of laparoscopy for treating recurrent inguinal hernia? <ul><li>Less recurrence </li></ul><ul><li>Less pain </li></ul><ul><li>Earlier return to activity </li></ul><ul><li>No missed hernia </li></ul>
  7. 7. What percentage of a general surgeon’s practice are recurrent hernias? <ul><li>Repair of recurrent hernia is a surrogate for actual recurrence rate. </li></ul><ul><li>The reoperation rate is not equal to the true recurrence rate but is a measure of recurrence serious enough to require reoperation. </li></ul><ul><li>The actual incidence of recurrence is higher than stated reoperation rates by at least 50% (1.7-2.3). </li></ul><ul><li>% Hernia Repairs that Present Overall in Population-based Studies and </li></ul><ul><li>Large Case Series </li></ul><ul><li>Nilsson 1998 (Denmark) 16% </li></ul><ul><li>Felix 1998 (USA) 14% </li></ul><ul><li>Liebl 1999 (Germany) 8.5% </li></ul><ul><li>Haapaniemi 2001 (Sweden) 15% </li></ul><ul><li>Bay-Nielson 2001 (Denmark) 17% </li></ul><ul><li>Bokeler 2007 (Germany) 14% </li></ul><ul><li>Bisgaard 2008 (Denmark) 3.1% </li></ul>
  8. 8. Consider - you have to be good at repairing recurrent inguinal hernias <ul><li>Bisgaard 2008 Danish Hernia Database (67,306 primary repairs) </li></ul><ul><ul><li>Recurrence rate of primary inguinal hernia repair – 3.1% </li></ul></ul><ul><ul><li>Recurrence rate after recurrent inguinal hernia repair – 8.8% </li></ul></ul><ul><li>Other studies demonstrate re-recurrence rates as high as 33% </li></ul><ul><li>Indeed, specialty centers show low recurrence rates for their </li></ul><ul><li>techniques. </li></ul><ul><ul><ul><li>Open tension free repair 0% – 8.30% </li></ul></ul></ul><ul><ul><ul><li>Laparoscopic TAPP repair 0% – 1.04% </li></ul></ul></ul>
  9. 9. Re-recurrence after TAPP for recurrence (national and large studies) <ul><li>Reference Year Pts/Hrns PT RT (no. Pts or Hrns) RR (%) </li></ul><ul><li>Haapaniemi 2001 NA/2,688 Ant. TAPP, TEP (670) 1.79 </li></ul><ul><li>Licht. (685) 1.46 </li></ul><ul><li>Plug (276) 2.54 </li></ul><ul><li>Other Mesh (574) 3.83 </li></ul><ul><li>Non-mesh (483) 4.35 </li></ul><ul><li>Bay-Nielson 2001 NA/3,943 Var. TAPP (560) 2.9 </li></ul><ul><li>TEP (78) 1.3 </li></ul><ul><li>Muscle (645) 6.7 </li></ul><ul><li>Licht. (1,697) 3.2 </li></ul><ul><li>Plug (212) 3.8 </li></ul><ul><li>Plug and patch (358) 3.6 </li></ul><ul><li>Other mesh (393) 5.6 </li></ul><ul><li>Wara 2005 NA/6,689 Unilateral recurrent hernia </li></ul><ul><li>Licht. Lap. (1,361; 92% TAPP) 4·63 </li></ul><ul><li>Licht. (4,633) 4·79 </li></ul><ul><li>Bilateral recurrent hernia </li></ul><ul><li>Licht. Lap (498; 92% TAPP) 2·61 </li></ul><ul><li>Licht. (172) 7·56 </li></ul><ul><li>Bokeler 2008 1,689/1,755 Ant. TAPP 0.6 </li></ul><ul><li>Bisgaard 2008 NA/1,124 Licht. Lap. (388; 95% TAPP) 1.3 </li></ul><ul><li>Licht. (344) 11.3 </li></ul><ul><li>Non-mesh (198) 19.2 </li></ul><ul><li>Mesh (non-Licht.) (194) 7.2 </li></ul><ul><li>Pts, patients; Hrns, hernias; PT, primary technique; RT, recurrent technique; RR, recurrence rate; NA, not available; </li></ul><ul><li>Var., various; TAPP, trans-abdominal pre-peritoneal repair; TEP, totally extra-peritoneal repair; Licht., Lichtenstein </li></ul><ul><li>repair; Lap, laparoscopy </li></ul>
  10. 10. TEP for recurrent inguinal hernia <ul><li>Reference Year Pts RT RRR </li></ul><ul><li>Bay-Nielson 2001 78 TEP 1.3% </li></ul><ul><li>1,697 Licht 3.2% </li></ul><ul><li>645 Muscle repair 6.7% </li></ul><ul><li>Kouhia 2009 49 TEP 0.0% </li></ul><ul><li>Prospective randomized 47 Licht 6.4% </li></ul><ul><li>Pts: patients; RT: recurrent technique; RRR: re-recurrence rate; </li></ul><ul><li>TEP: totally extra-peritoneal repair; Licht.: Lichtenstein repair </li></ul>
  11. 11. Pain score after TAPP for recurrent inguinal hernia <ul><li>Reference Year Technique No. of Patients Median VAS </li></ul><ul><li>Beets 1999 TAPP/GPRVS 42/37 2.2/2.9 (p = 0.05) </li></ul><ul><li>Mahon 2003 TAPP/Licht. 60/60 2.8/4.3 (p = 0.003) </li></ul><ul><li>Dedemadi 2006 TAPP/Licht. 24/32 1.0/2.0 (p = 0.001) </li></ul><ul><li>Eklund 2007 TAPP/Licht. 73/74 125 mm/165 mm </li></ul><ul><li>(p = 0.019) </li></ul><ul><li>Neumayer 2004 Lap./Lich. Difference in VAS </li></ul><ul><li>Day of surgery 10.2 mm (favoring TAPP) </li></ul><ul><li>Two weeks after surgery 6.1 mm (favoring TAPP) </li></ul><ul><li>Three months after surgery No difference </li></ul><ul><li>VAS, visual analog of pain score; TAPP, trans-abdominal pre-peritoneal repair; </li></ul><ul><li>GPRVS, giant prosthesis for reinforcement of visceral sac; Licht., Lichtenstein </li></ul><ul><li>repair; Lap, laparoscopy </li></ul>
  12. 12. Pain score after TEP for inguinal hernia <ul><li>Reference Year Technique No. of Patients Median VAS </li></ul><ul><li>Bringman 2003 TEP/Licht/Mesh-plug 92/103/104 1/2/2 (p = 0.001) </li></ul><ul><li>Eklund 2007 TEP/Licht 675/706 105/175 (p = 0.001) </li></ul><ul><li>Chronic Pain </li></ul><ul><li>Kouhia 2009 TEP/Licht 47/49 4/13 (p = 0.02) </li></ul><ul><li>VAS: visual analog of pain score; TEP: totally extra-peritoneal repair; </li></ul><ul><li>Licht: Lichtenstein repairs </li></ul>
  13. 13. Return to regular activity after TAPP for recurrent inguinal hernia <ul><li>Reference Year Technique Median days to return to work / activity </li></ul><ul><li>Beets 1999 TAPP/GPRVS 13/23 (p = 0.03) </li></ul><ul><li>Mahon 2003 TAPP/Licht 11/42 (p < 0.001) </li></ul><ul><li>Neumayer 2004 Lap./Licht. 4/5 (adj. HR 1.2; 95% CI 1.1 - 1.3) </li></ul><ul><li>Dedemadi 2006 TAPP/Licht 14/20 (p = 0.001) </li></ul><ul><li>Eklund 2007 TAPP/Licht 8/16 (p = 0.001) </li></ul><ul><li>TAPP, trans-abdominal pre-peritoneal repair; GPRVS, giant prosthesis for reinforcement </li></ul><ul><li>of visceral sac; Licht., Lichtenstein repair; HR, hazard ratio; CI, confidence interval; Lap, </li></ul><ul><li>laparoscopy </li></ul>
  14. 14. Return to regular activity after TEP inguinal hernia repair <ul><li>Reference Year Technique Median days to return to work / activity </li></ul><ul><li>Bringman 2003 TEP/Licht/Mesh-plug 14/25/29 (p < 0.0001) </li></ul><ul><li>Eklund 2007 TEP/Licht 7/12 (p <0.001) </li></ul><ul><li>Kouhia 2009 TEP/Licht 15/18 (p = 0.05) </li></ul><ul><li>TEP, totally extra-peritoneal repair; Licht., Lichtenstein repair </li></ul>
  15. 15. <ul><li>Crawford found an incidence of 8% occult femoral hernia at laparoscopic repair, </li></ul><ul><li>and Felix found 9% concurrent femoral hernia. </li></ul><ul><li>Felix 1996 Recurrent Primary </li></ul><ul><li>n = 152 patients Femoral 9% 4% </li></ul><ul><li>n = 173 recurrent hernias Pantaloon 25% 14% </li></ul><ul><li>Chan’s series of 225 repairs of femoral hernia repairs demonstrated 50.9% had </li></ul><ul><li>concurrent Inguinal hernia </li></ul><ul><li>5.8% had bilateral femoral hernia and 18.2% had prior groin hernia repair. </li></ul><ul><li>Chan believes prior inguinal hernia repair may precipitate a femoral hernia (15 x </li></ul><ul><li>higher according to Mikklesen etal). </li></ul><ul><li>Bisgaard 2008 Repair type Femoral recur. Re-recurrence Rate </li></ul><ul><li>n = 2,117 re-operations Endoscopic rep. n = 34 0.00% </li></ul><ul><li> Open repair n = 161 8.07% </li></ul><ul><li>TAPP allows full visualization of the floor and avoids missed concomitant </li></ul><ul><li>ipsilateral or contralateral hernias. </li></ul>No missed hernia after TAPP/TEP for recurrent hernia
  16. 16. No missed hernia (femoral hernias) <ul><li>3,980 femoral hernia repairs from Swedish Hernia Register </li></ul><ul><li>1,490 men, 2,490 women </li></ul><ul><li>35.9% (n = 1,430) underwent emergency surgery versus 4.9% of inguinal hernia repair </li></ul><ul><li>Bowel resection - 22.7% of emergent femoral repair versus 5.4% of emergent inguinal repair </li></ul><ul><li>Women at higher risk than men (40.6% versus 28.1%) </li></ul><ul><li>Mortality 10 times greater versus elective repair </li></ul><ul><li>Dahlstrand et al. Ann Surg 2009 </li></ul>
  17. 17. 1. What is the role of TAPP/TEP after TAPP/TEP? Questions remaining in 2009
  18. 18. <ul><li>Study Primary Repair Recur. Repair Tech. Re-recurrence Follow up </li></ul><ul><li>Knook 1999 Various Lap. TAPP 0.0% 35 months </li></ul><ul><li>Review (n = 34) </li></ul><ul><li>Three institutions </li></ul><ul><li>n = 34 patients </li></ul><ul><li>n = 34 recurrent hernias </li></ul><ul><li>TAPP is a reliable technique for repair of recurrent hernia prior endoscopic repair. </li></ul><ul><li>Liebl 2000 TAPP (n =44) TAPP 0.0% 26 months </li></ul><ul><li>Review of TEP (n = 2) </li></ul><ul><li>Prospective </li></ul><ul><li>Single institution series </li></ul><ul><li>n = 44 patients </li></ul><ul><li>n = 46 recurrent hernias </li></ul><ul><li>Laparoscopic repair of recurrent inguinal hernia after TAPP can only be done by the </li></ul><ul><li>transperitoneal approach. </li></ul><ul><li>It is effective with low complication rates. It requires large mesh. For reoperation, it should be </li></ul><ul><li>reserved for the experienced endoscopic surgeon. </li></ul><ul><li>Kapiris 2001 TAPP (n=17) TAPP (n=16) 0.62% (all repairs) 45 months </li></ul><ul><li>Retrospective </li></ul><ul><li>Two institutions TAPP (n=16) </li></ul><ul><li>n = 3,017 patients </li></ul><ul><li>n = 3,530 total hernias </li></ul><ul><li>n = 388 recurrent hernias </li></ul><ul><li>TAPP is difficult but safe and effective, with high patient satisfaction, in the hands of the well </li></ul><ul><li>trained surgeon. </li></ul>TAPP/TEP after Recurrence of TAPP/TEP Hernia Repair
  19. 19. <ul><li>Study Primary Repair Recur. Repair Tech. Re-recurrence Follow up </li></ul><ul><li>Keider 2002 TAPP / TEP TAPP / TEP 0.0% 37 months </li></ul><ul><li>Review (n = 3) </li></ul><ul><li>Single institution </li></ul><ul><li>n = 3 re-operations by laparoscopy after 7 re-recurrences after laparoscopy </li></ul><ul><li>Laparoscopic recurrent hernia repair is effective and superior to historical series. It should be the method of choice if cost could be </li></ul><ul><li>reduced. </li></ul><ul><li>Bittner 2007 TAPP TAPP 0.74% NA </li></ul><ul><li>Review (n = 135) </li></ul><ul><li>Single institution </li></ul><ul><li>n = 135 recurrent hernias </li></ul><ul><li>TAPP can be performed for recurrent inguinal hernia after TAPP with low recurrence rate, but the learning curve is high. </li></ul><ul><li>Bisgaard 2008 Laparoscopic TAPP (+/- 95%) (n = 14) 7.1% NA </li></ul><ul><li>Review of prospective (n = 100) Lichtenstein (n = 73) 2.7% </li></ul><ul><li>Danish hernia registry Nonmesh (n = 8) 0.0% </li></ul><ul><li>n = 67,306 primary repairs Mesh (non-Licht.) (n = 5) 0.0% </li></ul><ul><li>n = 100 recurrent hernias after lap. </li></ul><ul><li>Laparoscopic repair is recommended for reoperation of a recurrence after primary Lichtenstein repair. </li></ul><ul><li>Trend favors laparoscopic repair of recurrence after non-mesh and non-Lichtenstein mesh primary repair. </li></ul><ul><li>Laparoscopic repair of recurrence after laparoscopic primary repair shows no advantage in terms of </li></ul><ul><li>re-recurrence. </li></ul>TAPP/TEP after Recurrence of TAPP/TEP Hernia Repair
  20. 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. 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. 22. 2. Do we have an answer for groin pain after hernia repair?
  23. 23. Nerves prone to injury at herniorraphy: anterior and posterior
  24. 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. 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. 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
  27. 27. Types of post-operative groin pain Neuropathic <ul><li>Perineural fibrosis </li></ul><ul><li>Neuroma </li></ul><ul><li>Nerve entrapment </li></ul><ul><li>Direct lesions due to stretching </li></ul><ul><li>contusion,electrical injury, </li></ul><ul><li>and partial or complete division </li></ul>Non- neuropathic <ul><li>Osteitis pubis </li></ul><ul><li>Stapalgia </li></ul><ul><li>Meshalgia </li></ul>Visceral <ul><li>Spermatic cord problems </li></ul><ul><li>Orchitis </li></ul><ul><li>Vas deferens issues </li></ul>
  28. 28. Non-surgical management <ul><li>Non-operative attempts at pain resolution include: </li></ul><ul><li>Biofeedback </li></ul><ul><li>Medications </li></ul><ul><li>Physical therapy </li></ul><ul><li>Percutaneous treatment with local anesthetics, steroids, phenol, alcohol, cryoprobes, radiofrequency destruction </li></ul><ul><li>Transcutaneous nerve stimulators </li></ul>
  29. 29. <ul><li>Surgical treatment for periosteal reaction or osteitis pubis consists of </li></ul><ul><li>removing suture materials, staples, bulky suture knots, and/or bulk </li></ul><ul><li>forming or rolled mesh material from the pubic tubercle area. </li></ul>Surgical management: mesh/staple removal Causes, prevention, and surgical management of postherniorrhaphy neuropathic inguidynia: Triple neurectomy with proximal end implantation. Amid PK. Hernia 2004; 8: 343–349.
  30. 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. 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. 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)
  33. 33. Surgical management: nerve identification <ul><li>Identification and preservation of nerves during open inguinal hernia repair reduce chronic incapacitating groin pain. </li></ul><ul><li>Chronic pain at 6 months after surgery was zero in those patients in whom all 3 nerves were identified and preserved, compared with the 40% incidence when these nerves were all divided, or 4.7% when not all nerves were identified. </li></ul>Influence of Preservation Versus Division of Ilioinguinal, Iliohypogastric, and Genital Nerves During Open Mesh Herniorrhaphy Prospective Multicentric Study of Chronic Pain Sergio Alfieri, MD, Ann Surg April 2006; 243: 553–558 * Univariate Analysis: Risk of Complaining of Pain at 6 Months According to Nerve Treatment **Multivariate Analysis:Risk of Complaining of Pain at 6 Months According to Nerve Treatment Nerves not ID’ed UA* RR 95%CI P MV** RR 95%CI P 1 0.9 0.2–3.4 NS 2.2 0.2–26.4 0.539 2 2.1 0.6–8.1 NS 12.4 1.3–115.3 0.027 3 3.8 1.2–11.4 0.019 19.2 2.3–157.7 0.006
  34. 34. 3. What is the role of laparoscopy in the complex inguinal hernia? <ul><li>Scrotal hernia </li></ul><ul><li>Incarcerated </li></ul><ul><li>Strangulated hernia: in the setting of peritonitis and bowel necrosis </li></ul>
  35. 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
  36. 36. What Are the Recommendations for Laparoscopic Management of Complex Hernias? Complex Hernia Type Management Recommendations Level of Evidence (Authors) Scrotal <ul><li>TAPP and TEP can be used with good results </li></ul><ul><li>Reserved for highly experienced TAPP/TEP surgeons </li></ul>III (Ferzli, Liebl, Palanivelu) Incarcerated Inguinal <ul><li>TAPP may be used for acute or chronic incarceration </li></ul><ul><li>TAPP allows easy inspection of questionable bowel </li></ul><ul><li>TEP may be used for acute or chronic incarceration </li></ul><ul><li>Must convert to intra-abdominal port to inspect bowel </li></ul><ul><li>Reserved for highly experienced TAPP/TEP surgeons </li></ul>IV (Palanivelu, Leibl, Rebuffat, Ishihara,Legnani, Scierski) III (Ferzli, Tamme, Saggar) Strangulated Hernia with Peritonitis <ul><li>Laparoscopic (TAPP or TEP) repair of strangulated hernia should be avoided in the setting of : </li></ul><ul><li>Frank peritonitis </li></ul><ul><li>Infected abdominal wall </li></ul><ul><li>Necrotic bowel </li></ul>IV (Liebl, Ishihara, Ferzli)
  37. 37. Conclusions: <ul><li>Laparoscopic inguinal hernia repair in 2009 is feasible for primary, bilateral and recurrent hernias. </li></ul><ul><li>The main challenge remains the learning curve. </li></ul><ul><li>A thorough knowledge of the anatomy is of utmost importance. </li></ul>
  38. 39. References <ul><li>Mahon D, Decadt M, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc 2003;17:1386–90 </li></ul><ul><li>Feliu X, Jaurrieta E, Vinas X, et al. Recurrent inguinal hernia: a ten year review. J Laparoendosc Adv Surg Tech A 2004;14:362–7 </li></ul><ul><li>Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc 2007;21:634–40 </li></ul><ul><li>Sarli L, Iusco D, Sansebastiano G, et al. Simultaneous repair of bilateral inguinal hernias: a prospective randomized study of open, tension-free versus laparoscopic approach. Surg Laparosc Endosc Percutan Tech 2001;11:262–7 </li></ul><ul><li>Bay-Nielson M, Kehlet H, Strand L, Malmstrom J, Andersen FH, Wara P, Juul P, Callesen T. Quality assessment of 26 304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet (2001) 358: 1124-1128  </li></ul><ul><li>EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh, meta-analysis of randomized controlled trials. Ann Surg 2002;235:322–32 </li></ul><ul><li>Neumayer L, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. New Eng J Med (2004) 350(18): 1819-1827 </li></ul><ul><li>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 </li></ul>
  39. 40. References <ul><li>Bisgaard T, et al. Re-recurrence after operation for recurrent inguinal hernia. A nationwide 8-year follow-up study on the role of type of repair. Ann Surg , 2008, 247(4):707-711 </li></ul><ul><li>Bay-Nielson M, Kehlet H, Strand L, Malmstrom J, Andersen FH, Wara P, Juul P, Callesen T. Quality assessment of 26 304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet   (2001) 358: 1124-1128  </li></ul><ul><li>Haapaniemi S, et al. Reoperation After Recurrent Groin Hernia Repair Ann Surg (2001), 234(1): 122–126 </li></ul><ul><li>Nilsson E, et al. Methods of repair and risk for reoperation in Swedish hernia surgery from 1992 to 1996. Brit J Surg (1998), 85: 1686–1691 </li></ul><ul><li>Amid PK, Shulman AG, Lichtenstein, IL. Open“tension-free” repair of inguinal hernias: the Lichtenstein technique. Eur J Surg (1996) 162:447-53 </li></ul><ul><li>Kark AE, Kurzer M, Belsham PA. Three thousand one hundred and seventy-five primary inguinal hernia repairs; advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg (1998) 86:447-56 </li></ul><ul><li>Beets GL, et al. Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia? A randomized controlled trial. Surg Endosc (1999) 13: 323–327 </li></ul><ul><li>Mahon D, et al. Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc (2003) 17: 1386-1390 </li></ul><ul><li>Dedemadi G, et al. Comparison of laparoscopic and open tension-free repair of recurrent inguinal hernias: a prospective randomized study. Surg Endosc (2006) 20: 1099-1104 </li></ul><ul><li>Eklund A, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc (2007) 21:634-40 </li></ul><ul><li>Sandbichler P, et al. Laparoscopic repair of recurrent inguinal hernia. Amer J Surg (1996) 171:366-368 </li></ul>
  40. 41. <ul><li>Felix EL, et al. Laparoscopic repair of recurrent hernia. Amer J Surg (1996) 172: 580-584 </li></ul><ul><li>Jarhult J, et al. Laparoscopic treatment of recurrent inguinal hernias: Experience from 281 operations. Surg Laparosc, Endosc & Perc Tech (1999) 9(2):115-118 </li></ul><ul><li>Memon MA, et al. Laparoscopic repair of recurrent hernias. Surg Endosc (1999) 13: 807–810 </li></ul><ul><li>Ramshaw B, et al. Laparoscopic inguinal hernia repair: Lessons learned after 1,224 consecutive cases. Surg Endosc (2001) 15: 50-54 </li></ul><ul><li>Hawasli A, et al. Laparoscopic transabdominal preperitoneal inguinal hernia repair for recurrent inguinal hernia. Am Surg (2002) 68: 303-308 </li></ul><ul><li>Keider A, et al. Laparoscopic repair of recurrent inguinal hernia: Long-term follow up. Surg Endosc (2002) 16: 1708-1712 </li></ul><ul><li>Wara P, et al. Prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia. Brit J Surg (2005) 92: 1277-1281 </li></ul><ul><li>Bökeler U, et al. TAPP: An ideal technique for the treatment of recurrent hernia after open repair. AHS, Scottsdale (2008) </li></ul><ul><li>Tantia O, et al. Laparoscopic repair of recurrent groin hernia: Results of a prospective study. Surg Endosc (2008) [Epub ahead of print] </li></ul><ul><li>Bittner R, Schwarz J, Recurrent Hernia; Prevention and Treatment VIII 26.3; How to treat recurrent inguinal hernia – TAPP </li></ul><ul><li>Knook MT, et al. Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy. 1999, 13: 1145-1147 </li></ul>References
  41. 42. <ul><li>Liebl B, et al. Recurrence after endoscopic transperitoneal hernia repair (TAPP): Causes, reparative techniques, and results of the reoperation. J Am Coll Surg 2000 190(6): 651-655 </li></ul><ul><li>Kouhia S, Huttunen S, SilvastiS, Heiskanen J, Ahtola H, Uotila-Nieminen M, Kiviniemi V, Hakala T Lichtenstein hernioplasty versus totally extraperitoneal laparoscopic hernioplasty in treatment of recurrent inguinal hernia—A prospective randomized trial. 2009 Ann Surg 249: 384-387 </li></ul><ul><li>Feliu X, Torres G, Vinas X, Martinez-Rodenas F, Fernandez-Sallent E, Pie J. Preperitoneal repair for recurrent inguinal hernia: laparoscopic and open approach. Hernia. (2004) 8(2): 113-6 </li></ul><ul><li>Knook MTT, Weidema WF, Stassen LPS, van Steensel CJ. Endoscopic total extraperitoneal repair of primary and recurrent inguinal hernias. Surg Endosc (1999) 13: 507–511 </li></ul><ul><li>Sayad P, Ferzli G. Laparoscopic preperitoneal repair of recurrent inguinal hernias. J Laparoendosc Adv Surg Tech A . (1999) 9(2): 127-30. </li></ul><ul><li>Aeberhard P, Klaiber C, Meyenberg A, Osterwalder A, Tschudi J. Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair - A multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC). Surg Endosc (1999) 13: 1115–1120 </li></ul><ul><li>Staarink M, van Veen RN, Hop WC, Weidema WF. A 10-year follow-up study on endoscopic total extraperitoneal repair of primary and recurrent inguinal hernia. Surg Endosc . (2008) 22(8): 1803-6 </li></ul><ul><li>van der Hem JA, Hamming JF, Meeuwis JD, Oostvogel HJ. Totally extraperitoneal endoscopic repair of recurrent inguinal hernia. Br J Surg. (2001) 88(6): 884-6 </li></ul><ul><li>Ramshaw BJ, Tucker JG, Duncan TD, Heithold D, Garcha I, Mason EM, Wilson JP, Lucas GW. Technical considerations of the different approaches to laparoscopic herniorrhaphy: an analysis of 500 cases. Am Surg. ( 1996) 62(1): 69-72. </li></ul><ul><li>Felix EL, Michas CA, McKnight RL. Laparoscopic repair of recurrent hernias. Surg Endosc. (1995) 9(2): 135-8 </li></ul>References
  42. 43. <ul><li>Thill V, Simeons C, Smets D, Ngongang C, da Costa PM. Long-term results of a non-ramdomized prospective mono-centre study of 1000 laparoscopic totally extraperitoneal hernia repairs. Acta Chir Belg. (2008) 108(4): 405-8 </li></ul><ul><li>Alani A, Duffy F, O’Dwyer PJ. Laparoscopic or open preperitoneal repair in the management of recurrent groin hernias. Hernia (2006) 10(2): 156-8 </li></ul><ul><li>Bingener J, Dorman JP, Valdes G. Recurrence rate after laparoscopic repair of recurrent inguinal hernias: have we improved? Surg Endosc. (2003) 17(11): 1781-3 </li></ul><ul><li>Feliu X, Jaurrieta E, Vinas X, Macarulla E, Abad JM, Fernandez-Sallent E. Recurrent inguinal hernia: a ten-year review. J Laparoendosc Adv Surg Tech A. (2004) 14(6): 362-7 </li></ul><ul><li>Frankum CE, Ramshaw BJ, White J, Duncan TD, Wilson RA, Mason EM, Lucas G, Promes J. Laparoscopic repair of bilateral and recurrent hernias. Am Surg. (1999) Sep;65(9): 839-42 </li></ul><ul><li>Barrat C, Surlin V, Bordea A, Champault G. Management of recurrent inguinal hernias: a prospective study of 163 cases. Hernia (2003) 7(3): 125-9 </li></ul><ul><li>Bringman S, Ramel S, Heikkinen TJ, Englund T, Westman B, Anderberg B. Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: a prospective randomized controlled trial. Ann Surg 2003 Jan;237(1): 142-7 </li></ul><ul><li>McCormack K, Scott NW, Go PM, Ross S, Grant AM; EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003;(1): CD001785 </li></ul><ul><li>G. S. Ferzli, T. Kiel. The role of the endoscopic extraperitoneal approach in large inguinal scrotal hernias. Surg Endosc (1997) 11: 299–302 </li></ul><ul><li>Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R. Scrotal hernias: a contraindication for an endoscopic procedure? Results of a single-institution experience in transabdominal preperitoneal repair. Surg Endosc (2000) 14: 289–292 </li></ul>References
  43. 44. <ul><li>Palanivelu C, Rangarajan M, John SJ. Modified technique of laparoscopic intraperitoneal hernioplasty for irreducible scrotal hernias (omentoceles): how to remove the hernial contents. Worl J Surg (2007) 31(9):1889-91 </li></ul><ul><li>Leibl BJ, Schmedt CG, Kraft K, Kraft B, Bittner R. Laparoscopic transperitoneal hernia repair of incarcerated hernias: Is it feasible? Results of a prospective study. Surg Endosc (2001) 15: 1179–1183 </li></ul><ul><li>Rebuffat C, Galli A, Scalambra MS, Balsamo F. Laparoscopic repair of strangulated hernias. Surg Endosc (2006) 20: 131–134 </li></ul><ul><li>Ishihara T, Kubota K, Eda N, Ishibashi S, HaraguchiY. Laparoscopic approach to incarcerated inguinal hernia. Surg Endosc (1996) 10: 1111–1113 </li></ul><ul><li>Legnani GL, Rasini M, Pastori S, Sarli D. Laparoscopic trans-peritoneal hernioplasty (TAPP) for the acute management of strangulated inguino-crural hernias: a report of nine cases. Hernia (2008) 12: 185-188 </li></ul><ul><li>Scierski A. Laparoscopic operations of incarcerated inguinal and femoral hernias. Wiad Lek (2004) 57(5-6): 245-248 </li></ul><ul><li>Ferzli G, Shapiro K, Chaudry G, Patel S. Laparoscopic extraperitoneal approach to acutely incarcerated inguinal hernia. Surg Endosc (2004) 18(2):228-31 </li></ul><ul><li>Tamme C, Scheidbach H, Hampe C, Schneider C, Köckerling F. Totally extraperitoneal endoscopic inguinal hernia repair (TEP). Surg Endosc (2003) 17(2): 190-195 </li></ul><ul><li>Aasvang EK, Kehlet H. The effect of mesh removal and selective neurectomy on persistent postherniotomy pain. Ann Surg 2009;249:327-34 </li></ul><ul><li>Lau H, Patil N, Yuen W. Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males Surg Endosc (2006) 20: 76–81 </li></ul>References
  44. 45. <ul><li>Eklund A, Rudberg A, Smedberg C, Enander LK, Leijonmark CE, Osterberg, J. Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair Br J Surg 2006 Sep;93(9):1060-8 </li></ul><ul><li>Dahlstrand, U, Wollert S, Nordin, P. Emergency femoral hernia repair a study based on a national register . Ann Surg 249; 384-387 </li></ul>References
  45. 47. TAPP after TAPP Hernia re-recurrence <ul><li>Reference Year Pts/R Hrns PT RT (no. Pts or Hrns) RRR </li></ul><ul><li>Knook 1999 34/34 Lap. TAPP (34) 0.0 </li></ul><ul><li>Liebl 2000 44/46 TAPP TAPP (44), TEP (2) 0.0 </li></ul><ul><li>Bittner 2007 NA/135 TAPP TAPP (135) 0.74 </li></ul><ul><li>Bisgaard 2008 NA/100 Lap. Lap (14; 95% TAPP) 7.1 </li></ul><ul><li>Licht. (73) 2.7% </li></ul><ul><li>Nonmesh (8) 0 </li></ul><ul><li>Mesh (non-Licht.) (5) 0 </li></ul><ul><li>Pts, patients; R Hrns, recurrent hernias; PT, primary technique; RT, recurrent technique; </li></ul><ul><li>RRR, rerecurrence rate; NA, not available; TAPP, trans-abdominal pre-peritoneal repair; </li></ul><ul><li>TEP, totally extraperitoneal repair; Licht., Lichtenstein repair; Lap, laparoscopy </li></ul>
  46. 48. TAPP and TEP for incarcerated femoral hernia <ul><li>Incarcerated femoral hernia can be repaired by TAPP or TEP </li></ul><ul><li>but literature has been limited to case reports </li></ul><ul><li>TAPP for incarcerated femoral hernia </li></ul><ul><li>Watson (n = 1) </li></ul><ul><li>Yau (n = 8) </li></ul><ul><li>Comman (n = 1) </li></ul><ul><li>Rebuffat (n = 7) </li></ul><ul><li>TEP for incarcerated femoral hernia </li></ul><ul><li>Ferzli (n = 1) </li></ul>
  47. 49. Combined laparoscopic and open treatment
  48. 50. <ul><li>Study Primary Repair Recur. Repair Tech. Re-recurrence Follow up </li></ul><ul><li>Sandbilcher 1996 Anterior (muscle) TAPP 0.5% 18 months Prospective </li></ul><ul><li>Single institution </li></ul><ul><li>n = 192 patients </li></ul><ul><li>n = 200 recurrent hernias </li></ul><ul><li>Laparoscopic repair can be applied to recurrent hernia with low morbidity and recurrence. </li></ul><ul><li>Felix 1996 Anterior (not sp.) TAPP (n = 124) 0.58% 2 years </li></ul><ul><li>Review TEP (n = 49) </li></ul><ul><li>Single institution </li></ul><ul><li>n = 152 patients </li></ul><ul><li>n = 173 recurrent hernias </li></ul><ul><li>Laparoscopy helps eliminate early failure resulting from missed hernia and intrinsic weakness. </li></ul><ul><li>Jarhult 1999 Anterior (not sp.) TAPP (n = 113) 11% 49 months </li></ul><ul><li>Review TEP (n = 168) 2% </li></ul><ul><li>Single institution </li></ul><ul><li>n = 260 patients </li></ul><ul><li>n = 281 recurrent hernias </li></ul><ul><li>After a learning curve, laparoscopic repair of recurrent hernia can be performed with low recurrence. </li></ul><ul><li>TEP is preferable. TAPP used primarily during early period. Later, TEP used primarily. </li></ul><ul><li>Recurrence rate decreased from 23% (1st year) 8% (2nd year) 1% (3rd year) 4% (4th year) </li></ul>Recurrence after TAPP/TEP for Prior Hernia Repair Recurrence
  49. 51. <ul><li>Study Primary Repair Recur. Repair Tech. Re-recurrence Follow up </li></ul><ul><li>Beets 1999 Anterior (not sp.) TAPP (n = 56) 12.5% </li></ul><ul><li>34 months </li></ul><ul><li>Randomized controlled trial GPRVS (n = 52) 1.9% </li></ul><ul><li>n = 79 patients </li></ul><ul><li>n = 93 recurrent hernias </li></ul><ul><li>n = 15 concomitant primary hernias </li></ul><ul><li>Laparoscopic recurrent hernia repair has lower morbidity vs. GPRVS but is difficult and has higher recurrence rate. </li></ul><ul><li>Memon 1999 Anterior (not sp.) Laparosopic </li></ul><ul><li>27 months </li></ul><ul><li>Review TAPP (n = 68) 2.94 % </li></ul><ul><li>Three institutions TEP (n = 8) 0 </li></ul><ul><li>n = 85 patients IPOM (n = 19 ) 10.53% </li></ul><ul><li>n = 96 recurrent hernias Unknown (n = 1) 0 </li></ul><ul><li>Laparoscopic recurrent hernia repair is safe, with acceptable recurrence and complication rates. </li></ul><ul><li>Haapaniemi 2001 Anterior (not sp.) Lap. (TAPP and TEP) 1.79% (0.4) </li></ul><ul><li>2 years </li></ul><ul><li>Review of prospective (n = 670) </li></ul><ul><li>Swedish hernia registry Lichtenstein (n = 685) 1.46% (0.4) </li></ul><ul><li>n = patient total not provided Plug (n = 276) 2.54% (0.9) </li></ul><ul><li>n = 2,688 recurrent hernias Other Mesh (n = 574) 3.83% ( 0.9) </li></ul><ul><li> Non-mesh (n = 483) 4.35% ( 1.0) </li></ul><ul><li>Study supports use of laparoscopy or anterior tension-free repair of recurrent hernia. </li></ul>Recurrence after TAPP/TEP for Prior Hernia Repair Recurrence
  50. 52. <ul><li>Study Primary Repair Recur. Repair Techn. Re-recurrence Follow up </li></ul><ul><li>Bay-Nielson 2001 Various TAPP (n = 560) 2.9% NA </li></ul><ul><li>Review of prospective TEP (n = 78) 1.3% </li></ul><ul><li>Danish Hernia Registry Muscle repair (n = 645) 6.7% </li></ul><ul><li>n = patient total not provided Lichtenstein (n = 1,697) 3.2% </li></ul><ul><li>n = 3,943 recurrent hernias Plug (n = 212) 3.8% </li></ul><ul><li> Plug and patch (n = 358) 3.6% </li></ul><ul><li> Other mesh (n = 393) 5.6% </li></ul><ul><li>Mesh repairs have lower reoperation rates than conventional open repair. </li></ul><ul><li>Hawasli 2002 Anterior (not sp.) TAPP (screen and plug) 0.7% 5 years </li></ul><ul><li>Review </li></ul><ul><li>Single institution </li></ul><ul><li>n = 120 patients </li></ul><ul><li>n = 135 recurrent hernias </li></ul><ul><li>Recurrent hernia rate is high. These patients have a tendency toward contralateral hernia. Most recurrences </li></ul><ul><li>occur after 10 years. TAPP is a good repair for recurrent inguinal hernia </li></ul><ul><li>Keider 2002 Anterior TAPP (n = 115), 5.7% 37 months Review TEP (n = 15) </li></ul><ul><li>Single institution </li></ul><ul><li>n = 130 patients </li></ul><ul><li>n = 150 recurrent hernia </li></ul><ul><li>Laparoscopic recurrent hernia repair is effective and superior to historical series – it should be the method of </li></ul><ul><li>choice if cost could be reduced. </li></ul>Recurrence after TAPP/TEP for Prior Hernia Repair Recurrence
  51. 53. <ul><li>Study Primary Repair Recurrent Repair Technique Re-recurrence Follow up </li></ul><ul><li>Mahon 2003 Anterior (not sp.) TAPP (n = 60) 6.67% 3 months </li></ul><ul><li>Randomized Lichtenstein (n = 60) 1.67% </li></ul><ul><li>Prospective </li></ul><ul><li>Single institution </li></ul><ul><li>n = 120 patients </li></ul><ul><li>n = 42 recurrent, 71 bilateral and 7 both bilateral and recurrent hernias </li></ul><ul><li>TAPP is beneficial, in terms of pain and return to work, for patients undergoing bilateral or recurrent hernia </li></ul><ul><li>repair. </li></ul><ul><li>Neumayer 2004 Anterior (not sp) Laparoscopic (10% TAPP) (n = 81) 10.0% 2 years </li></ul><ul><li>Randomized Lichtenstein (n = 78) 14.1% </li></ul><ul><li>Prospective </li></ul><ul><li>Multi-center </li></ul><ul><li>n = 1,983 patients Experienced Laparoscopy (n >250) 3.6% </li></ul><ul><li>n = 1,983 total hernias (n = 28) </li></ul><ul><li>n = 159 recurrent hernias Experienced Lichtenstein (n >250) 17.2% </li></ul><ul><li>(n = 64) </li></ul><ul><li>Open mesh repair is superior to laparoscopy for primary hernia repair, but recurrence rates are similar for </li></ul><ul><li>recurrent hernia repair and for surgeons who are highly experienced. </li></ul>Recurrence after TAPP/TEP for Prior Hernia Repair Recurrence
  52. 54. <ul><li>Study Primary Repair Recur. Repair Techn. Re-recurrence Follow up </li></ul><ul><li>Dedemadi 2006 Anterior (not sp.) TAPP (n = 24) 8.33% 3 years </li></ul><ul><li>Prospective TEP (n = 26) 7.69% </li></ul><ul><li>Randomized Lichtenstein (n = 32) 15.63% </li></ul><ul><li>n = 82 patients </li></ul><ul><li>n = 82 recurrent hernias </li></ul><ul><li>Laparoscopic hernia repair is the method of choice for recurrent inguinal hernia. </li></ul><ul><li>Eklund 2007 Anterior (not sp.) TAPP (n = 73) 16.44% 5 years </li></ul><ul><li>Prospective Lichtenstein (n = 74) 16.23% </li></ul><ul><li>Randomized </li></ul><ul><li>Multi-center </li></ul><ul><li>n = 147 patients </li></ul><ul><li>n = 147 recurrent hernias </li></ul><ul><li>Laparoscopic hernia repair has the short term advantage of less post-op pain and shorter sick leave. </li></ul><ul><li>Bokeler 2008 Anterior (not sp.) TAPP 0.60% NA </li></ul><ul><li>Retrospective </li></ul><ul><li>Single institution </li></ul><ul><li>n = 1,689 patients </li></ul><ul><li>n = 1,755 recurrent hernias </li></ul><ul><li>Laparoscopic hernia repair should be the “Gold standard” in the treatment of recurrent hernias after anterior repair, but it is </li></ul><ul><li>essential to gain experience by using the laparoscopic technique for primary hernias. </li></ul>Recurrence after TAPP/TEP for Prior Hernia Repair Recurrence
  53. 55. <ul><li>Study Primary Repair Recurrent Repair Technique Re-recurrence Follow up </li></ul><ul><li>Bisgaard 2008 Lichtenstein TAPP (approx. 95%) (n = 388) 1.3% NA </li></ul><ul><li>Review of prospective Lichtenstein (n = 344) 11.3% </li></ul><ul><li>Danish hernia registry Nonmesh (n = 198) 19.2% </li></ul><ul><li>n = patient total not provided Mesh (non-Lichtenstein) (n = 194) 7.2% </li></ul><ul><li>n = 1,124 recurrent hernias </li></ul><ul><li>Laparoscopic repair is recommended for reoperation of recurrence after primary open Lichtenstein repair. Trend favors laparoscopic repair of </li></ul><ul><li>recurrence after non-mesh and non-Lichtenstein mesh primary repair. Laparoscopic repair of recurrence after laparoscopic primary repair shows </li></ul><ul><li>no advantage in terms of re-recurrence. </li></ul><ul><li>Tantia 2008 Anterior (not sp.) TAPP (n = 37), TEP (n = 28) 0.65% 36 months </li></ul><ul><li>Prospective </li></ul><ul><li>Single institution </li></ul><ul><li>n = 61 patients </li></ul><ul><li>n = 65 recurrent hernias </li></ul><ul><li>Laparoscopic repair of recurrent inguinal hernia is safe and effective with low morbidity and recurrence and should be the gold standard for these </li></ul><ul><li>hernias. </li></ul><ul><li>Kouhia 2009 49 TEP 0.0% </li></ul><ul><li>Prospective randomized 47 Licht 5 years 6.4% </li></ul><ul><li>Pts: patients; RT: recurrent technique; RRR: re-recurrence rate; TEP: totally extra-peritoneal repair; Licht.: Lichtenstein repair </li></ul>Recurrence after TAPP/TEP for Prior Hernia Repair Recurrence
  54. 56. Post-operative pain after TAPP/TEP for recurrent hernia <ul><li>Study Repair Technique Median Visual Analog </li></ul><ul><li>of Pain Score (VAS) </li></ul><ul><li>Beets 1999 </li></ul><ul><li>1 week after surgery TAPP (n= 42) 2.2 p = 0.005 </li></ul><ul><li> GPRVS (n = 37) 2.9 </li></ul><ul><li>Mahon 2003 Median VAS </li></ul><ul><li>24 hours after surgery TAPP (n = 60) 2.8 p = 0.003 </li></ul><ul><li> Lichtenstein (n = 60) 4.3 </li></ul><ul><li>Neumayer 2004 Difference in VAS </li></ul><ul><li>Pain at day of surgery 10.2 mm (favoring TAPP ) </li></ul><ul><li>Pain at two weeks after surgery 6.1mm (favoring TAPP ) </li></ul><ul><li>Pain at 3 month after surgery No difference </li></ul>
  55. 57. <ul><li>Study Repair Technique Median VAS </li></ul><ul><li>Dedemadi 2006 </li></ul><ul><li>Day of Surgery TAPP (n = 24) 4 p = 0.004 </li></ul><ul><li> Lichtenstein (n = 32) 5 </li></ul><ul><li>24 hrs after surgery TAPP 1 p = 0.001 </li></ul><ul><li> Lichtenstein 4 </li></ul><ul><li>7 days after surgery TAPP 1 p = 0.001 </li></ul><ul><li> Lichtenstein 2 </li></ul><ul><li> Analgesia use Mean analgesia use </li></ul><ul><li>TAPP 1.9 days p = 0.001 </li></ul><ul><li>Lichtenstein 3.2 days p = 0.001 </li></ul><ul><li>Eklund 2007 Median VAS </li></ul><ul><li>Pain at 1 week after surgery TAPP (n = 73) 125 mm p = 0.019 </li></ul><ul><li>Lichtenstein (n =74) 165 mm p = 0.001 </li></ul><ul><li>Median analgesia consumption decreased with TAPP vs Lichtenstein </li></ul><ul><li>The short term advantage for patients who undergo laparoscopic repair is less postoperative pain. </li></ul>Post-operative pain after TAPP/TEP for recurrent hernia
  56. 58. Return to work after TAPP/TEP for recurrent hernia <ul><li>Study Median Return to Work / Daily Activities </li></ul><ul><li>Beets 1999 TAPP 13 days (p= 0.03) </li></ul><ul><li> GPRVS 23 days </li></ul><ul><li>Mahon 2003 TAPP 11 days (p = < 0.001) </li></ul><ul><li> Lichtenstein 42 days </li></ul><ul><li>Neumayer 2004 Laparoscopy 4 days (adjusted hazard ratio 1.2; 95% CI, 1.1-1.3) </li></ul><ul><li> Lichtenstein 5 days </li></ul><ul><li>Dedemadi 2006 TAPP 14 days (p = 0.001) </li></ul><ul><li> Lichtenstein 20 days </li></ul><ul><li>Eklund 2007 TAPP 8 days (p=0.001) </li></ul><ul><li> Lichtenstein 16 days </li></ul><ul><li>Trend increased with increased occupational exertion (p = 0.001) </li></ul><ul><li>The short term advantage for patients who undergo laparoscopic repair is shorter sick leave. </li></ul>
  57. 59. TAPP and TEP for scrotal hernia <ul><li>Laparoscopic repair of the scrotal hernia is controversial and the literature on the subject is scarce. </li></ul><ul><li>1996 - Ferzli described laparoscopy for scrotal hernia in 17 patients. </li></ul><ul><ul><li>Utilized TEP. No recurrences. 1 </li></ul></ul><ul><li>1999 Liebl addressed subject of TAPP for scrotal hernia. </li></ul><ul><ul><li>191 prospectively studied TAPP repairs for scrotal hernias. </li></ul></ul><ul><ul><li>Sac rarely transected. </li></ul></ul><ul><ul><li>Operative times slightly increased vs. normal TAPP repair. </li></ul></ul><ul><ul><li>Minor complication rate: </li></ul></ul><ul><ul><li>12% for scrotal vs. 5% for routine TAPP repair. </li></ul></ul><ul><ul><li>Most common complication: seroma. </li></ul></ul><ul><ul><li>Major complication rate: 1.6% for scrotal vs. 0.6% for routine repair. </li></ul></ul><ul><ul><li>Recurrence rate was 1%. 2 </li></ul></ul><ul><li>Palanivelu also presented a small series of patients using TAPP to repair irreducible scrotal hernias with good results. 3 </li></ul>
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