This document discusses different types of hernia repair techniques including open and laparoscopic approaches. It provides details on various open tissue repair techniques as well as open mesh repairs like Lichtenstein repair. Laparoscopic repairs like TEP and TAPP are discussed along with their advantages of less pain and faster recovery compared to open repairs. However, laparoscopic repairs are noted to be more technically challenging. Several studies comparing open and laparoscopic outcomes are summarized, finding laparoscopic repairs result in less short-term pain and faster recovery but higher recurrence rates, especially among low-volume surgeons. The document emphasizes the importance of not reserving laparoscopic repairs only for more complex cases in order to overcome the learning curve.

1. ANDREW S. WRIGHT MD
DIRECTOR, UW MEDICINE HERNIA
CENTER
TWITTER: @ANDREWSWRIGHT
EMAIL: AWRIGHT2@UW.EDU
Open vs. MIS Inguinal Hernia

4. Types of hernia repair
 Open Tissue
 High Ligation
 Bassini
 McVay
 Halstead
 Shouldice
 Desarda
 Marcy
 Open Anterior Repair
 Lichtenstein
 Modified Lichtenstein
 Open Posterior Repair
 Plug
 OnStep
 Stoppa
 Open Hybrid repair
 Plug/patch
 PHS/UHS
 Lap Repair
 TEP
 TAPP
 rTAPP
 eTEP
 IPOM

5. Types of hernia repair
 Open Tissue
 High Ligation
 Bassini
 McVay
 Halstead
 Shouldice
 Desarda
 Marcy
 Open Anterior Repair
 Lichtenstein
 Modified Lichtenstein
 Open Posterior Repair
 Plug
 OnStep
 Stoppa
 Open Hybrid repair
 Plug/patch
 PHS/UHS
 Lap Repair
 TEP
 TAPP
 rTAPP
 eTEP
 IPOM
Lichtenstein Repair is Gold Standard

6.  Not all hernias are the same!

7.  Not all hernias are the same!

8. Hernia Outcomes that Matter

9. Hernia Outcomes that Matter
 Recurrence
 2-5%
 Highly dependent on Surgeon experience and volume

10. Outcomes that matter - Pain
 Chronic Pain
 8-20% Mesh sensation
 1-2% Daily pain
 0.1% Disabling

11. Outcomes that matter - Pain
 Chronic Pain
 8-20% Mesh sensation
 1-2% Daily pain
 0.1% Disabling
 770,000 hernia repairs annually

12. Outcomes that matter - Pain
 Chronic Pain
 8-20% Mesh sensation
 1-2% Daily pain
 0.1% Disabling
 770,000 hernia repairs annually
 77,000 patients with disabling pain

13. Outcomes that matter - Pain

14. Secondary Outcomes
 Cost
 OR time
 Return to work
 Cosmesis

15. Option: Watchful Waiting
 Acute event 1.8/1,000 patient years
 No limitation on exercise or activity

16. Option: Watchful Waiting
 Acute event 1.8/1,000 patient years
 No limitation on exercise or activity
 Crossover 76% at 7 years

17. Tissue Repair: why?
 20% Google searches for health information

18. Tissue Repair: why?
 20% Google searches for health information

19. Tissue Repair: why?
 20% Google searches for health information

20. Option 1: Tissue Repair
 Shouldice

21.  Shouldice
 Highly selected patient
 Technical and operator dependent

22.  Shouldice
 Cochrane review 2012 Shouldice vs. other open tissue repairs

23. Open Mesh (Lichtenstein) Repair
 Advantages
 Quick
 Reproducible
 Local anesthetic
 Low recurrence
 Disadvantages
 Foreign Body
 Proximity to nerves

24.  Shouldice
 Cochrane review 2012 Shouldice vs. mesh repairs

25.  Shouldice
 Cochrane review 2012 Shouldice vs. mesh repairs
No decrease in chronic pain in Shouldice vs.
Lichtenstein

26. Types of hernia repair
 Open Tissue
 High Ligation
 Bassini
 McVay
 Halstead
 Shouldice
 Desarda
 Marcy
 Open Anterior Repair
 Lichtenstein
 Modified Lichtenstein
 Open Posterior Repair
 Plug
 OnStep
 Stoppa
 Open Hybrid repair
 Plug/patch
 PHS/UHS
 Lap Repair
 TEP
 TAPP
 rTAPP
 eTEP
 IPOM
Lichtenstein Repair is Gold Standard

27. Lichtenstein
 Key step!
 Identification and preservation of nerves

28. Lichtenstein
 Key step!
 Identification and preservation of nerves
1/3 Reduction in pain at 3 months with intra-op
Marcaine nerve block

29. Lichtenstein modifications
 no-suture glue technique (TIMELI trial)
 Significant reduction in disabling pain
 No difference in recurrence

30. ProGrip

31. ProGrip mesh

32. Progrip
 Potential benefits
 Reduced risk of nerve injury
 Faster OR time
 Potential disadvantages
 Increased cost
 Increased inflammatory reaction
 Several single center RCTs
 Underpowered
 No difference in chronic pain or recurrence
 Possible increase in foreign body sensation

33. Options: Open Preperitoneal Groin
 Mesh Plug
 PHS – Prolene Hernia System
 UHS
 ONSTEP
 Insightra
 Kugel
 TREPP (transrectus preperitoneal)

34. Outcomes of open preperitoneal repair
 Most proprietary systems lacking data
 3 year outcomes no different than standard
Lichtenstein

35. My Recs
 Open preperitoneal repairs burn bridges
 Plug migration
 Meshoma
 No evidence that any proprietary system better than
Lichtenstein

37. Option: Open Preperitoneal (Midline)
 Stoppa Repair – Maximally invasive

38. Stoppa Repair

39. MIS Inguinal Hernia Repair

40. Laparoscopic Repair
 Advantages
 Less short term and chronic pain, Faster Recovery
 Address bilateral hernias, femoral hernias
 Avoid ilioinguinal and iliohypogastric nerves

41. Laparoscopic Repair
 Disadvantages
 Technically more challenging
 Better outcomes in RCTs and in expert hands

42. Lap vs Open: What Does the Data Say?
 Neumayer L et al. NEJM 2004: 350(18); 1819-1827.
 Multicenter randomized trial, VA
 1983 patients
 Two year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%

43. Lap vs Open: What Does the Data Say?
 Neumayer L et al. NEJM 2004: 350(18); 1819-1827.
 Multicenter randomized trial, VA
 1983 patients
 Two year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%
 Concluded: primary unilateral hernias should be repaired
with OIHR

44. Lap vs Open: What Does the Data Say?
 Neumayer L et al. NEJM 2004: 350(18); 1819-1827.
 Multicenter randomized trial, VA
 1983 patients
 Two year follow-up, recurrence rate Open 4.9% vs. Lap 10.1%
 Concluded: primary unilateral hernias should be repaired
with OIHR
 Critique:
 Average age of pts was high, health related QOL low c/w general
population
 VA Population
 Surgeon inexperience/learning curve
 Those with >250 cases had recurrence rate <5% in LIHR

45. Lap vs Open Inguinal Hernia
 Kouhia STH et al. Ann Surg 2009; 249(3): 384-387
 90 patients randomized
 6.4% recurrence in OIHR vs. 0% for TEP (ns)
 Higher incidence of chronic pain in OIHR group
 TEP group with less analgesic requirement and shorter return
to work

46. META-ANALYSIS
RANDOMIZED CLINICAL TRIALS
 29 trials
 5588 patients (3017 laparoscopic)
 6 outcomes evaluated
 Operating time, Time to discharge, Return to normal activity, Return
to work, Postoperative complications, Recurrence rate
 Favoring Lap:
 postop complications, return to normal activity, return to work, time to discharge
 Favoring Open:
 OR time (15min)
 No Difference in Recurrence
Memon, MA et al. Br J Surg 2003: 01: 1479-1492
COMPARING OPEN AND LAPAROSCOPIC
INGUINAL HERNIA REPAIR

47. Hernia Outcomes that Matter
 Recurrence
 2-5%
 Highly dependent on Surgeon experience and volume

48. Lap vs. Open
Lap
 Less Pain
 Faster Recovery
 Bilateral and Recurrent
 More operator
dependant
Open
 Easier to learn
 Reproducible
 Good results
Make a choice, don’t reserve lap for bilaterals and recurrence or you will never
overcome the learning curve

50. Questions?
awright2@uw.edu
Twitter: @andrewswright