Ing hernia  open vs lap ahm 2013 sept
Upcoming SlideShare
Loading in...5
×
 

Ing hernia open vs lap ahm 2013 sept

on

  • 753 views

 

Statistics

Views

Total Views
753
Views on SlideShare
753
Embed Views
0

Actions

Likes
0
Downloads
5
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Treating inguinal hernias BMJ 2004;328:59–60 VOLUME 328 10 JANUARY 2004 bmj.com Andrew Kingsnorth professor of surgery Derriford Hospital, Plymouth PL6 8DH andrew.kingsnorth@phnt.swest.nhs.uk)
  • Prospective Randomized Trial- 2164 patients at 14 Veteran ’ s Affairs medical centers to receive open or laparoscopic procedure. The surgical protocol was standardized for each type of procedure, and surgeons must have performed at least 25 of their chosen procedure to qualify for the study. Patients were followed up for two years, and 1696 (86%) completed the follow up. Patients who had lap repair experienced less pain after surgery and returned to work sooner (4 v 5 days; 95%). However, the difference in pain was generally minor, between 6 and 10 on a 100 point visual scale There were more complications with lap repair, including more life threatening complications (0.1% v 1.1%; odds ratio 11.2, 1.3 to 95.3). The recurrence rate at two years was also lower in the open repair group (4.9% v 10.1%) Bottom line Although lap repair is associated with a small reduction in pain and gets your patient back to work a day sooner, it carries a greater risk of serious complications and recurrence.

Ing hernia open vs lap ahm 2013 sept Presentation Transcript

  • 1. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 1Herniacon Ahmedabad 12-15 Sept, 2013 Medical Director Nova Medical Centers Pvt Ltd, India Consultant Surgeon Minimal Access and Bariatric Surgery Nova Specialty Surgery, Koramangala & Manipal Hospital, Bangalore Greetings From…. Dr. M G Bhat MS, FRCS(England), FRCS ( Edinburgh), FICS DMLE (Law), DMIRCSEd (Informatics)
  • 2. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 2Herniacon Ahmedabad 12-15 Sept, 2013 Inguinal Hernia Open Hernia Repair Is this the end of the Road?
  • 3. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 3Herniacon Ahmedabad 12-15 Sept, 2013 Inguinal Hernia - epidemiology • Very Common • Life Time Risk: % : 27 M :3 F • >20million Repairs/yr/worldwide • 100-300 / 100000 / yr • 100,000 in UK /yr • 800,000 in US • Approx > ?? in India /yr 1. Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835-9. 2. Kingsnorth AN, LeBlanc KA. Management of abdominal hernias. 3rd ed.London, New York: Edward Arnold, 2003:40-7. 3.Samir S A, Shawn P F .Current Approach to Inguinal Hernia Repair. Am J Surg 2004;188-6;9-16 4. Richard Burnley: http://online.epocrates.com/u/2942723/inguinal+hernia 2012 Dec: BMJ Content
  • 4. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 4Herniacon Ahmedabad 12-15 Sept, 2013 Treatment Options .1 Acute: Irreducible, Strangulated, Obstructed or Uncertain viability of the bowel Open: Preferred Approach by most Surgeons Lap: Few Published Reports
  • 5. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 5Herniacon Ahmedabad 12-15 Sept, 2013 • Paper Based of the review of literature: 43 articles found: • 16 reported use of Lap • 7 reported exclusive use of Laparoscopy • and were fully reviewed. • 328 cases • 6 Conversions • Average Stay 4 days • 34 Complications ( Mostly Minor) • 17 Resections ( by lap or mini laparotomy) Laparoscopic Approach to Incarcerated and Strangulated Inguinal Hernia: S Deeba, E Zacharakis et all. JSLS(2009)13:327-331
  • 6. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 6Herniacon Ahmedabad 12-15 Sept, 2013 Treatment Options .2 Large or Symptomatic Hernia Open: Preferred Approach by most Surgeons Lap: Preferred- on the expertise the Surgeon
  • 7. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 7Herniacon Ahmedabad 12-15 Sept, 2013 • Size and Type of Hernia • Technical Capability • Access to Facility • Previous Operations • Cost factors What Repair ? How to select ?
  • 8. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 8Herniacon Ahmedabad 12-15 Sept, 2013 What techniques in 2013>>>>? • 95% Open Mesh- Lichtenstein • 5% Laparoscopy EU Hernia Trialists Collaboration Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized trials. Br J Surg 2000;87:860-7. ….And Many other Publications
  • 9. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 9Herniacon Ahmedabad 12-15 Sept, 2013 Repair Types used in USA (as of 2003) Procedure Total & (%) Lichtenstein 229500 (37) Plug 227000 (34) Laparoscopy 111500 (14) Other meshes 65000 (8) Tissue Repairs 55000 (7) SS Awad, SP Fagan. Current Approaches to Inguinal Hernia Repair. Am J Surg;2004;188-6;9-16
  • 10. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 10Herniacon Ahmedabad 12-15 Sept, 2013 Treatment Options .3 Recurrent or Bilateral Hernia Lap: Preferred Approach. To be done by Lap Surgeons Open: Done by All other Surgeons
  • 11. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 11Herniacon Ahmedabad 12-15 Sept, 2013 • Laparoscopy safe, comfortable, cost effective What is Best for – Bilateral ? A prospective German Study- Schmedt CG, Daubler P, Leibl BJ, Kraft K, Bittner R. Simultaneous bilateral laparoscopic inguinal hernia repair. Surg Endosc. 2002;16:240- 244
  • 12. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 12Herniacon Ahmedabad 12-15 Sept, 2013 Recurrent Hernia..? • Following Open- Lap • Following Lap - Open
  • 13. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 13Herniacon Ahmedabad 12-15 Sept, 2013 80 yrs/M with IHD and Respiratory Problems .. What Repair?
  • 14. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 14Herniacon Ahmedabad 12-15 Sept, 2013 Treatment Options .4 High Surgical Risk Patients Open: Preferred Approach Under Local Anesthesia Lap: Not suitable For GA
  • 15. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 15Herniacon Ahmedabad 12-15 Sept, 2013 Which is Better - Open or Lap ? N Engl J Med 2004;350:1819-27. (www.nejm.org) Prospective Random Study comparing- Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia. Neumayer L, Giobbie-Hurder A, Jonasson O, et all. for the Veterans Affairs Cooperative Studies Program 456 Investigators • Lap - Pain Less • Lap – Early Return to Work • But Higher Risk of Serious Complications and Recurrence
  • 16. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 16Herniacon Ahmedabad 12-15 Sept, 2013 Open Hernia ..When? • Large Hernia • Complicated Hernia • Lap Recurrent Hernia • Previous Surgery ?
  • 17. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 17Herniacon Ahmedabad 12-15 Sept, 2013 Lap Hernia ..When? • Fit Patients • Uncomplicated Hernia • Bilateral & Recurrent • Cost Factor??
  • 18. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 18Herniacon Ahmedabad 12-15 Sept, 2013 2004 revised recommendations…. • Lap repair to be considered for first time management of unilateral inguinal hernias 2001 Recommendation…. • Open Mesh Repair preferred approach for primary hernia • Laparoscopy for Recurrent and Bilateral Hernia NICE (National Inst for Clinical Excellence, UK)
  • 19. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 19Herniacon Ahmedabad 12-15 Sept, 2013 National Institute of Health and Excellence (NICE Guidelines) UK TA83 Hernia laparoscopic surgery (review) (TA83) Technology appraisals TA83 Issued: September 2004
  • 20. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 20Herniacon Ahmedabad 12-15 Sept, 2013 Laparoscopic surgery can be used as an option for repairing inguinal hernia. As with all surgery, there are some risks involved, which may include serious problems just after the operation, pain or numbness in the area of the operation, and the hernia coming back. Your doctor should tell you about the risks and benefits of each of the types of surgery (open surgery, or laparoscopic surgery using either the TAPP or TEP methods) before you make a decision on which method to have. NICE ….
  • 21. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 21Herniacon Ahmedabad 12-15 Sept, 2013 In helping you make this decision you and your doctor should particularly consider: 1. How well you are likely to cope with a general anesthetic 2. First or Recurrent 3. Unilateral or Bilateral 4. Open or Lap is the best 5. Surgeons Experience NICE has also said that laparoscopic surgery for inguinal hernia repair by TAPP or TEP should only be performed by specially trained surgeons who regularly carry out the procedure. NICE ….
  • 22. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 22Herniacon Ahmedabad 12-15 Sept, 2013 BMJ. 2003 May 10;326(7397):1012-3. Prospective randomized controlled trial of lap vs open Both with good long term results & low recurrence
  • 23. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 23Herniacon Ahmedabad 12-15 Sept, 2013 The Surgeon FactorThe Surgeon Factor The Surgeon isThe Surgeon is the most importantthe most important prognostic factor.prognostic factor. The Skills and Experience of the SurgeonThe Skills and Experience of the Surgeon are more important than the type ofare more important than the type of repair.repair. Wantz,Hernia,1994Wantz,Hernia,1994
  • 24. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 24Herniacon Ahmedabad 12-15 Sept, 2013 Treatment Options .5 Operate or Not in Hernia ? • Very High Surgical Risk Life Expectancy Limited Refuse Repair Small & Asymptomatic Hernia Can Conside r Watchfu l Waiting Can Conside r Watchfu l Waiting Safer to Avoid ! Safer to Avoid !
  • 25. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 25Herniacon Ahmedabad 12-15 Sept, 2013 NICE Guidelines 2004 With seemingly similar results and complications the choice between the two procedures should firmly be based on the surgeon’s experience and preference
  • 26. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 26Herniacon Ahmedabad 12-15 Sept, 2013 POEM is the present Philosophy… • Patient • Oriented • Evidence that • Matters Patient-Oriented Evidence that Matters (editorial BMJ 2002;325:983) www.infoPOEMs.com/informationmastery.cfm
  • 27. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 27Herniacon Ahmedabad 12-15 Sept, 2013 http://dx.doi.org/10.1136/bmj.f3795 (Published 11 June 2013) BMJ 2013;346:f3795 News: BMJ June 2013 Surgeons Performance data to be available from July
  • 28. Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY drmgbhat@gmail.com 28Herniacon Ahmedabad 12-15 Sept, 2013 Thank you