Laparoscopic Inguinal Herniorrhaphy Pros and Cons

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  • From here to eternity
  • Laparoscopic Inguinal Herniorrhaphy Pros and Cons

    1. 1. Laparoscopic inguinal herniorrhaphy PROS AND CONS George Ferzli MD, FACS Professor of Surgery SUNY Downstate
    2. 2. Where is the controversy?
    3. 3. Only open hernias can be done with spinal or local anesthesia
    4. 4. But then:
    5. 5. But then:
    6. 6. Recurrent hernias cannot be repaired via laparoscopy
    7. 7. But then: Laparoscopic preperitoneal repair of recurrent inguinal hernias P. Sayad, G Ferzli J Laparoendosc Adv Surg Tech A 9:127-130 (1999)
    8. 8. 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
    9. 9. Scrotal hernias cannot be repaired laparoscopically
    10. 10. But then:
    11. 11. Another advantage of laparoscopy:
    12. 12. Recurrences after a laparoscopic inguinal hernia repair must be done via an open approach
    13. 13. But then:
    14. 14. What do the prospective randomized studies show?
    15. 15. 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
    16. 16. Throughout the evolution of laparoscopic hernia repair certain outcome measures have been evaluated to validate the procedure <ul><li>Recurrence rate </li></ul><ul><li>Complications </li></ul><ul><li>Operative time </li></ul><ul><li>Postoperative pain </li></ul><ul><li>Return to work </li></ul><ul><li>Cost </li></ul><ul><li>Reproducibility </li></ul>
    17. 17. …We reviewed… <ul><li>All Prospective Randomized studies comparing open to laparoscopic hernia repair </li></ul><ul><li>38 studies from 1990 to 2000 </li></ul>
    18. 19. Laparoscopic Recurrences <ul><li>Mesh too small </li></ul><ul><li>Use of incised mesh </li></ul><ul><li>Inadequate dissection and missed cord lipoma </li></ul><ul><li>Displacement of mesh </li></ul>Leibl. J Am Coll Surg. 2000; 190 :651
    19. 20. Recurrence Rate <ul><li>Most recurrences are technical failures. </li></ul><ul><li>Recurrences are more common during the learning phase of laparoscopic repair. </li></ul><ul><li>In experienced centers, recurrence rates equal or fall below those of open repair techniques. </li></ul>
    20. 22. Complications <ul><li>Complications occur that are unique to laparoscopic repair (e.g. trocar injuries). </li></ul><ul><li>Laparoscopic complications tend to be more serious than open (e.g. vascular and bowel injuries). </li></ul><ul><li>Complication rates are higher during the learning phase of laparoscopic repair. </li></ul><ul><li>In experienced centers, complication rates equal or fall below those of open repair techniques. </li></ul>
    21. 24. Operative Time <ul><li>All comparative series show longer operative times for laparoscopic repair. </li></ul><ul><li>Operative time is longer during the learning phase of laparoscopic repair. </li></ul><ul><li>Laparoscopic bilateral repairs have been shown to be shorter than open. </li></ul><ul><li>In experienced centers, the duration of laparoscopic repair at best is shown to be statistically similar to open repair. </li></ul>
    22. 26. Postoperative Pain <ul><li>Is assessed differently from study to study. </li></ul><ul><ul><li>Pain scoring scales </li></ul></ul><ul><ul><li>Tracking analgesic administration </li></ul></ul><ul><ul><li>Measuring post operative exercise tolerance </li></ul></ul><ul><li>Most comparative series show a significant benefit in the laparoscopic repair groups. </li></ul>
    23. 28. Return to Work <ul><li>Time off work seems to be related to the type of </li></ul><ul><ul><li>hernia (unilateral vs bilateral : primary vs recurrent) </li></ul></ul><ul><ul><li>repair technique </li></ul></ul><ul><ul><li>occupation </li></ul></ul><ul><li>Most comparative series show a significant benefit in the laparoscopic groups. </li></ul>
    24. 30. Swanstrom. Surg Clin N Am. 2000; 80 :1341
    25. 31. Swanstrom. Surg Clin N Am. 2000; 80 :1341
    26. 32. Cost <ul><li>If only material and equipment costs are evaluated, laparoscopic repair is more expensive. </li></ul><ul><li>If time off work is considered, laparoscopic repair can be shown to be modestly cheaper than open repair. </li></ul><ul><li>Significant reductions in the cost of laparoscopic repair can be achieved by eliminating unnecessary and disposable equipment. </li></ul>
    27. 33. Outcome Measures
    28. 34. …We reviewed… <ul><li>All studies regarding the learning curve </li></ul><ul><li>16 studies from 1989 to 1999 </li></ul><ul><li>Only 3 studies attempted quantitative analysis, suggesting 30-50 cases to achieve technical proficiency </li></ul>
    29. 35. … but where is the greatest impact of the learning curve?
    30. 36. …We reviewed… <ul><li>Surgical resident and chief resident operative experience in laparoscopic cholecystectomy and herniorrhaphy over a 10-year period </li></ul><ul><li>ACGME General surgery database from 1989 to 1999 </li></ul>
    31. 37. Resident Experience in Cholecystectomy
    32. 38. Resident Experience in Hernia Repair
    33. 42. Given the data regarding training experience, we can only conclude that our graduating residents are not beyond the learning curve.
    34. 43. In order for lap inguinal hernia results to be equal to open hernia, surgeons must be beyond their own learning curve

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