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Laparoscopic Inguinal Herniorrhaphy Pros and Cons
 

Laparoscopic Inguinal Herniorrhaphy Pros and Cons

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Laparoscopic Inguinal Herniorrhaphy Pros and Cons Laparoscopic Inguinal Herniorrhaphy Pros and Cons Presentation Transcript

  • Laparoscopic inguinal herniorrhaphy PROS AND CONS George Ferzli MD, FACS Professor of Surgery SUNY Downstate
  • Where is the controversy?
  • Only open hernias can be done with spinal or local anesthesia
  • But then:
  • But then:
  • Recurrent hernias cannot be repaired via laparoscopy
  • But then: Laparoscopic preperitoneal repair of recurrent inguinal hernias P. Sayad, G Ferzli J Laparoendosc Adv Surg Tech A 9:127-130 (1999)
  • Then the instruments became smaller Surg Endosc 13:822-823 (1999) © 1999 by Springer-Verlag New York, Inc. Needlescopic extraperitoneal repair of inguinal hernias G. Ferzli, P. Sayad, J. Nabagiez
  • Scrotal hernias cannot be repaired laparoscopically
  • But then:
  • Another advantage of laparoscopy:
  • Recurrences after a laparoscopic inguinal hernia repair must be done via an open approach
  • But then:
  • What do the prospective randomized studies show?
  • Mesh infection 0.08% Bladder injury 0.1% Bowel injury 0.1% Neuralgia 0.1% TEP 1182 Ferzli/2002 Mesh infection 0.02% Hematoma 1.8% Neuralagia 0.3% TEP 5203 Tamme/2003 Recurrence 0.7% Conversion 0.1% Bleeding 0.5% Mesh infection 0.1% Trocar site hernia 0.7% Nerve injury 0.3% Bladder injury 0.1% Bowel injury 0.1% TAPP 8050 Bittner/2002 Recurrence 0.4% TAPP 5163 TEP 4890 10053 Felix/1998 Complications TAPP vs. TEP N=Hernias Author/Year
  • Throughout the evolution of laparoscopic hernia repair certain outcome measures have been evaluated to validate the procedure
    • Recurrence rate
    • Complications
    • Operative time
    • Postoperative pain
    • Return to work
    • Cost
    • Reproducibility
  • …We reviewed…
    • All Prospective Randomized studies comparing open to laparoscopic hernia repair
    • 38 studies from 1990 to 2000
  •  
  • Laparoscopic Recurrences
    • Mesh too small
    • Use of incised mesh
    • Inadequate dissection and missed cord lipoma
    • Displacement of mesh
    Leibl. J Am Coll Surg. 2000; 190 :651
  • Recurrence Rate
    • Most recurrences are technical failures.
    • Recurrences are more common during the learning phase of laparoscopic repair.
    • In experienced centers, recurrence rates equal or fall below those of open repair techniques.
  •  
  • Complications
    • Complications occur that are unique to laparoscopic repair (e.g. trocar injuries).
    • Laparoscopic complications tend to be more serious than open (e.g. vascular and bowel injuries).
    • Complication rates are higher during the learning phase of laparoscopic repair.
    • In experienced centers, complication rates equal or fall below those of open repair techniques.
  •  
  • Operative Time
    • All comparative series show longer operative times for laparoscopic repair.
    • Operative time is longer during the learning phase of laparoscopic repair.
    • Laparoscopic bilateral repairs have been shown to be shorter than open.
    • In experienced centers, the duration of laparoscopic repair at best is shown to be statistically similar to open repair.
  •  
  • Postoperative Pain
    • Is assessed differently from study to study.
      • Pain scoring scales
      • Tracking analgesic administration
      • Measuring post operative exercise tolerance
    • Most comparative series show a significant benefit in the laparoscopic repair groups.
  •  
  • Return to Work
    • Time off work seems to be related to the type of
      • hernia (unilateral vs bilateral : primary vs recurrent)
      • repair technique
      • occupation
    • Most comparative series show a significant benefit in the laparoscopic groups.
  •  
  • Swanstrom. Surg Clin N Am. 2000; 80 :1341
  • Swanstrom. Surg Clin N Am. 2000; 80 :1341
  • Cost
    • If only material and equipment costs are evaluated, laparoscopic repair is more expensive.
    • If time off work is considered, laparoscopic repair can be shown to be modestly cheaper than open repair.
    • Significant reductions in the cost of laparoscopic repair can be achieved by eliminating unnecessary and disposable equipment.
  • Outcome Measures
  • …We reviewed…
    • All studies regarding the learning curve
    • 16 studies from 1989 to 1999
    • Only 3 studies attempted quantitative analysis, suggesting 30-50 cases to achieve technical proficiency
  • … but where is the greatest impact of the learning curve?
  • …We reviewed…
    • Surgical resident and chief resident operative experience in laparoscopic cholecystectomy and herniorrhaphy over a 10-year period
    • ACGME General surgery database from 1989 to 1999
  • Resident Experience in Cholecystectomy
  • Resident Experience in Hernia Repair
  •  
  •  
  •  
  • Given the data regarding training experience, we can only conclude that our graduating residents are not beyond the learning curve.
  • In order for lap inguinal hernia results to be equal to open hernia, surgeons must be beyond their own learning curve