Hernia and Abdominal Wall Reconstruction 2017
•Download as PPTX, PDF•
1 like•331 views
This document summarizes a conference on hernia surgery and abdominal wall reconstruction held in London in February 2017. It discusses the need for centralized hernia surgery centers to improve outcomes. The document also provides details on hernia surgery volumes and trends at Aintree University Hospital from 2012-2016, showing a decline. It argues that Aintree needs to establish a dedicated hernia and abdominal wall reconstruction center to be competitive and reverse its declining hernia surgery volumes.
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Hernia and Abdominal Wall Reconstruction 2017
Similar to Hernia and Abdominal Wall Reconstruction 2017 (20)
More from Raimundas Lunevicius
More from Raimundas Lunevicius (20)
Recently uploaded
Recently uploaded (20)
Hernia and Abdominal Wall Reconstruction 2017
- 1. HERNIASURGERY & ABDOMINAL WALL RECONSTRUCTION: time for change 2nd Europe conference, 2 – 4 Feb, 2017 Raimundas Lunevicius, Khalid Shahzad General Surgery Department Aintree University Hospital NHS Foundation Trust, Liverpool, England 14th Mar 2017 1AWR Europe 2017
- 2. 2nd Europe conference, 2 – 4 Feb, 2017 Venue • RCP, London • Two co-chairs from UCL • 300 participants • 24 countries David Ross & Al Windsor 2AWR Europe 2017 Photography, Raimundas Lunevicius
- 3. Four key messages 1. Results of incisional hernia repair are not good 2. Centralized hernia surgery is a prerequisite for improvement of clinical outcomes 3. Center for a hernia and AWR should be an essential component of a university hospital 4. Hernia and abdominal wall reconstructive surgery is a practical and academic sub-specialisation 3AWR Europe 2017
- 4. Requirements for successful hernia project 1. Decision & strong institutional support - is a key 2. Dedicated faculty / consultants 3. Commitment for clinical & academic excellence 4. MDT 5. Dedicated general surgeons 6. Plastic surgeon 7. Radiologist, anesthetist, etc. 8. A wound-healing specialist 9. ANP 10. Clinic 11. Theatre with dedicated theatre staff 12. Prospectively maintained database for independent data managers / collectors / analytics 4AWR Europe 2017
- 5. Global discussions (selected as examples) 1. Anatomy & assessment of the AW 2. WHO, World, European, Germany guidelines (RCS & NICE – not discussed) 3. Management of acute abdominal defect 4. Negative pressure wound therapy & dressings 5. Management of hernia disease 6. Hernia disease classifications 7. Recurrent hernia risk stratification and reduction 8. Prevention of SSI & incisional hernia 5AWR Europe 2017
- 6. Lectures on technical aspects of hernia surgery • Origins of component separation for AWR (Ramirez procedure) Ramirez OM, Ruas E, Delon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519-26 6AWR Europe 2017 Photography, Raimundas Lunevicius
- 7. Incisional hernia repair methods • Technical details of component separation (if indicated): • Anterior component separation (ACS) with on-lay / under-lay mesh • Importance of perforator sparing in ACS • Rives-Stoppa procedure & its further extension into • Posterior component separation (PCS) or Transverse Abdominal Release (TAR) with under-lay mesh • Preoperative preparation is a key when the contents of a hernia has lost their ‘right of domicile’ (radiology) 1. A role of Botox type-A for pre-op. chemical component separation 2. The preoperative progressive pneumoperitoneum • with or without use of Botox type-A 7AWR Europe 2017
- 8. Prosthetic materials: classification 1. Synthetic non-absorbable meshes with or without absorbable collagen layers 2. Synthetic gradually absorbed meshes (GORE BIO-A Tissue Reinforcement) 3. Fully biological prosthesis from bovine, porcine, or human matrix (Integra, Strattice, Permacol) 4. Semi-biological devices: a combination of an extracellular matric and a synthetic mesh ‘Zenapro’ (Cook Medical) NB! Physiological response of the host is most physiologic to the biological meshes 8AWR Europe 2017
- 9. Management and prevention of morbidity • Seroma • Very common after on-lay placement of a mesh • Forget on-lay placement of a mesh, when possible • Drains do not prevent; however, use them • Visceral injury: 1-1.8% • a recognized complication in laparoscopic hernia surgery • insertion of a first port laterally is most dangerous maneuver • Infection: • consider early surgery • Skin necrosis: • consider early surgery • Recurrence • Centralized work reduces recurrent hernia rate two times or even more 9AWR Europe 2017
- 10. Presentations from Merseyside • Whiston • Two presentations • commercialized • Arrow Park: • One poster • CRP profile following hernia repair • Aintree University • Nil • Royal Liverpool: • Nil 10AWR Europe 2017 © Bimal Kumar Kanhar, NGS
- 11. Hernia Disease: where the UK and England stands? • Incidence 11AWR Europe 2017
- 12. ASIR per female person-year in 2015 2,300 cases per 100,000 females in 2015, UK (95% UI 2,200 – 2,400) INCIDENCE of ventral hernia among females - HIGHESTINTHE WORLD 12Abdominal wall hernia incidence. EpiViz, GBD 2015
- 13. ASIR per male person-year in 2015 6,000 cases per 100,000 males in 2015, UK (95% UI 5,600 – 6,600): Ventral hernia disease incidence among males is the HIGHESTINTHE WORLD in the UK 13Abdominal wall hernia incidence globally. EpiViz, GBD 2015
- 14. The UK 14AWR Europe 2017
- 15. ASIR per female person-year in 2015, UK 2,800 cases per 100,000 females in 2015, UK (95% UI 2,700 – 2,900): North West region: HIGHESTINCIDENCEAMONG FEMALES 15Abdominal wall hernia incidence: England, N. Ireland, Scotland, Wales. EpiViz, GBD 2015
- 16. ASIR per male person-year in 2015, UK 6,400 cases per 100,000 males in 2015, UK (95% UI 5,900 – 7,000) 16Abdominal wall hernia incidence: England, N. Ireland, Scotland, Wales. EpiViz, GBD 2015
- 17. Aintree University Hospital • Hernia surgery activities • Elective and emergency procedures combined 17AWR Europe 2017
- 18. Aintree: Hernia surgery volume, 2012 – 2016 (elective and emergency cases combined) Total of Number of Procedures Year Hernia surgery type 2012 2013 2014 2015 2016 Grand Total Incisional hernia repair 16 6 14 8 80 124 Umbilical/Periumbilica l hernia repair 128 153 146 155 139 721 Linea alba/Spigelian hernia repair 46 49 30 45 27 197 Inguinal hernia repair 326 367 328 340 312 1673 Femoral hernia repair 20 19 17 22 19 97 Lumbar hernia repair - 1 1 4 2 8 Other hernia repair 118 143 114 129 64 568 Grand Total 654 738 650 703 643 3388 18 ABI, 2017 AWR Europe 2017
- 19. 19 This funnel plot shows all primary, bilateral inguinal hernia repair procedures on adults per 100,000 population per CCG across England, for the year 2014/15. Each bubble represents a CCG, with the size of the bubble representing the number of procedures undertaken. Taken from http://rcs.methods.co.uk/pet.html
- 20. Aintree: Hernia surgery volume, 2012 – 2016 (elective and emergency cases combined) Total of Number of Procedures Year Hernia surgery type 2012 2013 2014 2015 2016 Grand Total Incisional hernia repair 16 6 14 8 80 124 Umbilical/Periumbilical hernia repair 128 153 146 155 139 721 Linea alba/Spigelian hernia repair 46 49 30 45 27 197 Inguinal hernia repair 326 367 328 340 312 1673 Femoral hernia repair 20 19 17 22 19 97 Lumbar hernia repair - 1 1 4 2 8 Other hernia repair 118 143 114 129 64 568 Grand Total 654 738 650 703 643 3388 20 ABI, 2017 AWR Europe 2017
- 21. Decline in hernia surgery procedures,Aintree 21ABI, 2017 654 738 650 703 643 580 600 620 640 660 680 700 720 740 760 2012 2013 2014 2015 2016 Grand total 43.6 46.1 38.2 41.4 33.8 0 5 10 15 20 25 30 35 40 45 50 2012 2013 2014 2015 2016 Hernia repair procedures per consultant capita a year
- 22. Interpretation • Losing competitive battle • Historical and current policy for a hernia and abdominal wall reconstructive surgery requires essential revision ‘The rejection of Fact, the rejection of Reason is the Path to decline’ (NY, 2017) 22AWR Europe 2017
- 23. Acenter for hernia and AWR at Aintree University Hospital NHS Foundation Trust • First job: • To say categorical ‘YES’ in Gen. Surg. Directorate Meeting today • Afterwards: other talks of a secondary importance such as • Planning • Structure: MTD team, data base, data manager • Pathways • SOPs • Marketing • Formal approval • Start • Regular analysis will follow 23 Thank you, Raimundas Lunevicius Conclusions
Editor's Notes
- Two Aintree doctors – Khalid Shahzad and myself – were privileged to attend an AWR Europe 2017 conference in Feb because two other consultants general surgeons – Mr. Misra and Mr. Taylor – agreed to cover Emergency General Surgery and major trauma units from the 2nd day to the 4th day of February. Thank you both very much.
- The venue was organized by David Ross and Al Windsor in RCP. There were 300 participants from 24 countries.
- The faculty of conference send four key messages for everyone, but especially for consultants from university hospitals. They are follows: 1, 2, 3, 4.
- Before any new start, a preparatory work should be completed. Requirements for successful hernia project are as follows: 1-12.
- There were a lot of global discussions in the conference. A few examples: 1 – 8.
- There were lectures on technical aspects of hernia surgery. It has been a pleasure to listen Dr. Ramirez – an inventor of component separation method for AWR in Johns Hopkins University hospital in 1990.
- Please DO NOT think that component separation method is a remedy for all incisional hernia diseases or acute abdominal defects. Absolutely NOT. However, a general as well as plastic surgeon must understand the principles of ACS, perforator sparing, Rives-Stoppa procedure and its further extension into PCS or TAR. Preoperative preparation is a key for some patients with large hernia defects. A role of BOTOX-type A, therefore, has also been discussed in the conference.
- All prosthetic materials for hernia repair are classified into 4 groups: 1- 4. Please bear in mind, that physiological response of the host is most physiologic to the biological meshes.
- No big news from the world of management and prevention of morbidity after hernia repair.
- To understand the magnitude of a hernia market in the UK, I would like to show you 4 slides on the incidence of ventral hernia disease.
- This map shows the ASIR per female person-year in 2015. ASIR = Age standardized incidence rate. Largest surgical market in the world.
- ASIR = Age standardized incidence rate. Largest surgical market in the world.
- ASIR = Age standardized incidence rate. North West: largest surgical market in England.
- ASIR = Age standardized incidence rate. North West and South West: largest surgical markets in England.
- This table shows the total numbers of hernia repair procedures in adults in Aintree between 2012 and 2016. I think that the overall numbers, as well as numbers for inguinal hernia repair procedures in adults at Aintree look OK. However, I do not know how many PRIMARY BILATERAL inguinal hernia repair procedures we do a year.
- This funnel plot shows all PRIMARY, BILATERAL INGUINAL HERNIA REPAIR procedures on adults per 100,000 population per CCG across England, for the year 2014/15. Each bubble represents a CCG, with the size of the bubble representing the number of procedures undertaken. I think that CCGs for Aintree hidden within two inner lines of this funnel plot. However, it is just my assumption.
- If you could have a look at the numbers for incisional hernia repair procedures – 16 in 2012, 6 in 2013, 14 in 2014, 8 in 2015 - where would CCGs for Aintree be in a analogical funnel plot? Below the lowest blue line of a funnel plot as an outlier and outsider? On the other hand, I think that 80 incisional hernia repair procedures in 2016 mean that some invisible activities are taking place at Aintree. And that possibly means a positive qualitative shift from 2016.
- FURTHERMORE, please have a look at both trend-lines for Aintree. First, figure on the left side of the slide shows a decline in hernia surgery between 2012 and 2016. Second, a trend-line showing decline looks even more profound when hernia surgery activities have been divided by consultant capita a year.
- Ladies and gentleman, we are losing a competitive battle for a patient and for a market. Therefore, I think that historical and current policy for a hernia and abdominal wall reconstructive surgery requires essential revision for Aintree.
- To conclude, it is a time to think about a newly organized center for hernia and AWR at Aintree. If so, I suggest to document YES in the Gen Surg Direct Meeting today. Afterwards, other talks of a secondary importance such as - Planning, Structure, Pathways, SOPs, Marketing, Formal approval, Start, Regular Analysis - will follow.