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Hernias: Who, What, When, Where, Why?

J. Scott Roth, MDChief, Gastrointestinal Surgery

Director, Minimally Invasive SurgeryUniversity of Kentucky

June 16, 2009

ObjectivesIdentify patients at risk for herniasUnderstand the etiology and pathophysiology of

herniasReview the demographics of patients with herniasDiscuss common hernia locations and associated

signs and symptomsUnderstand why (or why not) a hernia should be

repairedProvide an overview of techniques for hernia repair

and associated controversies

Common hernia types Inguinal Hernia

Hernia:The protrusion of an organ or other bodily

structure through the wall that normally contains it; a rupture.; p

Inguinal:Of, relating to, or located in the groin.

Myopectineal Orifice of Fruchaud

MPOSuperior- arched fibers of int.

obliqueInferior – iliac boneMedial – rectus abdominis m. Lateral – iliopsoas & iliopectineal arch

Hesselbach’s Triangle

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Inguinal Hernia

U.S. Abdominal Hernia Repairs 2003

Inguinal hernia 770,000Femoral hernia 30,000Umbilical hernia 175,000Epigastric, spigelian, etc. 80,000Incisional hernia 105,000

Based on projected growth from 1996 National Survey of Ambulatory Surgery and National Center for Health Statistics

Hernia Repairs

Sex(%) Age(%)Procedure M F <15 15-44 45-64 >65Inguinal Hernia 90 10 18 29 23 30Inguinal Hernia 90 10 18 29 23 30Femoral Hernia 30 70 <1 19 29 48Umbilical Hernia 57 33 13 33 36 17Incisional Hernia 35 65 <1 25 35 39Others –spig/epig 43 57 1 32 40 26

Hernia Management

Non-operativeTrus/Hernia beltOperative

Medical Management

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External Support Watchful Waiting

Randomized Prospective Trial720 men over 5 years – repair vs. observation

Pain limiting activities 5.1% vs. 2.2% NS23% WW patients cross over to repair23% WW patients cross over to repair17% cross over to WW from repair armComplications similar in initial repair/crossover rep.

2 patients with incarceration events – 1.8/1000 pt-yrsNo strangulation events

Fitzgibbons et al. JAMA 2006

Modern Hernia Repairs

Unchanged from 1890-1980Primary tissue repairMany repair types Fundamentally similar

sutured repair, tension, prolonged recovery, disability, and high recurrence

“It will seem extremely bold to write about the radical repair of inguinal hernias, especially nowadays after all the publications in the past and the restless activity in the present. I thought of a surgical technique of physiological g q p y greconstruction of the inguinal canal, consisting of two openings, an abdominal and a subcutaneous, and of two walls, a posterior and an anterior, with the spermatic cord between them.”

Bassini 1889

Fathers of Inguinal Hernia Repair

Marcy1871 – original paper on antiseptic hernia

repair with closure of internal ringJAMA 1887 The Cure of Hernia

Bassini reported 1887, published 1889

HalstedNovember 1889

Modified Bassini Repair

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Shouldice Hernia Repair

Repair established in 1952 at Shouldice hospitalCommonly referred to as the Bassini-Shouldice

repairMany similarities to Bassini except four layers ofMany similarities to Bassini except four layers of

running suture to reconstruct posterior inguinal wall

Local Anesthesia – first to popularize inguinal herniorrhaphy under local anesthesia

Shouldice Repair

Shouldice ComplicationsTesticular atrophy – 0.36%Hematomas – 0.3%Infections – 1%Hydroceles – 0.7%yDysejaculation – 0.25%Mortality – 0.009%Recurrence rate - 0.5% primary; 1.5%recurrent

250,000 repairs over 20 years

CB McVayThe Pathologic Anatomy of the More Common

Hernias and their Anatomic Repair 1954

McVay Hernia Repair Tension Free Hernia RepairsThe past twenty years

1980s – increase in numbers of tension free repairs

1990 b f t i f i1990s – number of tension free repairs surpasses sutured repairs

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Trends in Hernia Repair

200000

250000

300000

350000

BassiniMcVay

0

50000

100000

150000

200000

1970 1980 1990 1995 2000 2003

McVayShouldiceLichtensteinLaparoscopic

Groin Hernia Repairs

Procedure Type Number % Lichtenstein 295,000 37%Plug 270,000 34%Laparoscopy 115,000 14%Other Mesh 65,000 8%Tissue rep 55,000 7%

Lichtenstein Hernia Repair1984 – the tension-free hernioplasty project begun at the Lichtenstein

Hernia InstituteInguinal floor is reinforced by mesh prosthesisMesh placed between transversalis fascia and external oblique

aponeurosis8 x 16 cm polypropylene meshp yp pyRunning suture to inguinal ligamentTwo interrupted sutures superiorly(rectus sheath and internal oblique5cm of mesh lateral to internal ring

A multi-center experience with 6,764 Lichtenstein tension-free hernioplasties

Amid PK, Friis E, Horeyseck, Kux M. Hernia 1999;3(S12):47

6,764 Inguinal Hernia repairs4 surgeons at 4 institutions

Recurrence rate 0.1 to 0.9 percentComplications – infection, seroma,

hematoma, neuralgia ~ 1%

Stoppa RepairGiant Prosthetic Reinforcement of the Visceral Sac

(GPRVS)

Polyester mesh to correct the structural weakness of the groin

Sutureless repair through self-stabilizationp g

Techniquemidline or pfannensteil incisionpreperitoneal approach

Stoppa et. al. Surg Clin N Am 1984

Stoppa Repair

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Stoppa RepairGiant Prosthetic Reinforcement of the Visceral Sac

(GPRVS)Total patients 1992Septic complications 2.1%Follow up rate 79.2%Follow up duration 2-12 yearsRecurrence rate: overall 1.1%

primary hernia 0.56%recurrent hernia 1.3%

Laparoscopic Inguinal Herniorrhaphy

First described in 1990Techniques

PlugClosure of internal ringIPOM – intraperitoneal only of meshTAPP – transabdominal properitonealTEP – totally extraperitoneal

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Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for Inguinal-Hernia Repair

Liem et al. NEJM 1997

Randomized Multicenter Trial – 87 surgeonsprimary and initially recurrent unilateral inguinal herniasp y y g

487 Extraperitoneal laparoscopic repairs507 Anterior repairs – Bassini(29%), Shouldice(22%),

Bassini-McVay(19%), McVay(9%),others

Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for Inguinal-Hernia Repair

Liem et al. NEJM 1997

Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for Inguinal-Hernia Repair

Liem et al. NEJM 1997

Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for Inguinal-Hernia Repair

Liem et al. NEJM 1997

Recurrence rate

Open 31 (6%)Open 31 (6%)Laparoscopic 17 (3%)

p=.05

Cost-Effectiveness of Extraperitoneal Laparoscopic Inguinal Hernia Repair: A Randomized Comparison with

Conventional HerniorrhaphyLiem et. al. Ann Surg 1997

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Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair

Memon et al. Br J Surg 2003

Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair

Memon et al. Br J Surg 2003

ConclusionsLaparoscopic Hernia repair

decreased hospital stayquicker return to normal activity/workq yfewer postoperative complicationsLonger operating timestrend toward higher short term recurrences in

laparoscopic (NS)

Study Design

14 Veterans Affairs medical centers2164 patients randomly assigned

Lichtenstein technique Laparoscopic repair (TAPP or TEP)

2 year follow up

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Open Mesh Versus Laparoscopic Mesh Repair of Inguinal HerniaNeumayer et al. NEJM 2004

Primary Hernia recurrencesLaparoscopic 79/781 (10.1%)Lichtenstein 30/756 (4.0%)

Recurrent Hernia RerecurrencesLaparoscopic 8/81 (10.0%)Lichtenstein 11/78 (14.1%)

Open Mesh Versus Laparoscopic Mesh Repair of Inguinal HerniaNeumayer et al. NEJM 2004

Highly experienced Surgeons (>250 cases)Primary Hernia Recurrences Recurrent Hernia recurrence

Lap 13/253 (5.1%) Lap 1/28 (3.6%)Open 26/635 (4.1%) Open 11/64 (17.2%)

Inexperienced SurgeonsPrimary Hernia Recurrences Recurrent Hernia Recurrence

Lap 65/528 (12.3%) no statistical powerOpen 3/121 (2.5%)

97/989 (10%) Lap patients converted to open – various reasons

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…“a hernia repair is equivalent to repairing drywall”……

The Baltimore Sun August 13, 2006

Incisional Hernias

Common clinical problemMore than 10% of laparotomy incisions

1.3 million laparotomies per year150,000 hernias created annually

6-15% incidence of incarceration2% incidence of strangulation

Biology of HerniasMechanisms of Recurrence

infection, lateral detachment of mesh, inadequate mesh fixation, inadequate mesh, inadequate mesh overlap

Inlay with 2.5 fold increased recurrence compared to underlay, sandwich, overlay

Awad et al. JACS 201(1):132-140, 2005

Smokers with a 4 Fold increase in Incisional Hernia formation

Sorenseon et al. Arch Surg 140:119-123, 2005

Decreased Collagen I/III ratio associated with hernia formation

Junge et al. Langenbecks Arch Surg 389:17-22, 2004

Incisional Hernia Repairs in Non-Federal US Hospitals

Carlson et al. Hernia 2008

Flum et al. Ann Surg 137(1):129-135, 2003

Progression to Hernia RecurrenceWashington State Database 1987-1999

10,822 patients

12%5 years

23%13 years

Flum et al. Ann Surg 137(1):129-135, 2003

5 years

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Rates of Reoperation Primary vs. Mesh Repair

Luijendijk RW, Luijendijk RW, et al; NEJM, et al; NEJM, 20002000

Progression to Reoperation by use of mesh Open Incisional Hernia Repair

• Overlay• Inlay• Underlay• Sandwich• Rives-Stoppa technique

Pascal’s Principle

Blaise Pascal (1623-1662)

liquid in a closed container at rest t it h ith t ltransmits a pressure change without loss to the walls

pressure in a gas or fluid is the same in all directions

Physiology of Hernias

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Law of LaPlace

Wall tension(T) is proportional to pressure(P) and radius(R)

Increased Radius Increased tensionT i l ti l t ll thi k (M)T inversely proportional to wall thickness(M)

T= P x R / 2MT= tensionP= pressureR= radiusM= wall thickness

Physiology of Hernias

r

25

30

35

40

Complications and Recurrence are Decreased with Laparoscopic Approach

0

5

10

15

20

25

Complications Recurrence

LapOpen

Hiatal HerniasHiatal Hernias

22--5% of population 5% of population Pathophysiology poorly understoodPathophysiology poorly understood95% of HHs are Sliding Type I hernias95% of HHs are Sliding Type I hernias

69% asymptomatic69% asymptomatic27% small HH with reflux27% small HH with reflux35% large(>2cm) with reflux35% large(>2cm) with reflux

Paraesophageal hernias 2Paraesophageal hernias 2--5%(types 2,3,4)5%(types 2,3,4)

Hiatal Hernias: definedHiatal Hernias: defined

Type 1: GE Junction intermittently migrates Type 1: GE Junction intermittently migrates into mediastinuminto mediastinum

Type 2: GE Junction anchored at Type 2: GE Junction anchored at diaphragm with herniation of adjacent diaphragm with herniation of adjacent p g jp g jstomach into mediastinumstomach into mediastinum

Type 3: Combined Type 1 and 2Type 3: Combined Type 1 and 2Type 4: Viscera other than stomach in Type 4: Viscera other than stomach in

mediastinummediastinum

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Hiatal Hernia: Type 1Hiatal Hernia: Type 1

Type 1: GE Junction intermittently migrates into mediastinumType 1: GE Junction intermittently migrates into mediastinum

Hiatal Hernia: Type 2Hiatal Hernia: Type 2

Type 2: GE Junction anchored at diaphragm with herniation of adjacent Type 2: GE Junction anchored at diaphragm with herniation of adjacent stomach into mediastinumstomach into mediastinum

Type IIIType III

Type 3: Combined Type 1 and 2Type 3: Combined Type 1 and 2

Type IVType IV

Type 4: Viscera other than stomach in MediastinumType 4: Viscera other than stomach in Mediastinum

Paraesophageal Hernia Paraesophageal Hernia Types 2,3 & 4Types 2,3 & 4

30% present with severe complications if untreated30% present with severe complications if untreatedHill, Tobias, Arch Surg 96:735Hill, Tobias, Arch Surg 96:735--744, 1968744, 1968

Tremendous controversyTremendous controversyEvaluationEvaluationEvaluationEvaluationWhen to operate When to operate –– if at allif at allWhich operationWhich operation

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PresentationPresentation

Often asymptomaticOften asymptomaticSuspicion based on Suspicion based on imagingimaging

Volvulus

Asymptomatic Paraesophageal Hernia Asymptomatic Paraesophageal Hernia RepairRepair

Paraesophageal Hernias: Operation or ObservationParaesophageal Hernias: Operation or ObservationStylopoulos et al Annals of Surgery 236(4): 492Stylopoulos et al Annals of Surgery 236(4): 492--501, 2002501, 2002

Markov ModelMarkov ModelMinimally symptomatic type 2 and 3 HHs (reflux sx only)Minimally symptomatic type 2 and 3 HHs (reflux sx only)Pooled data for elective repair death rate (0Pooled data for elective repair death rate (0--5.2%)5.2%)1997 NIS database mortality for emergency repair (5.4%)1997 NIS database mortality for emergency repair (5.4%)

Literature suggests 17%Literature suggests 17%Literature suggests 17%Literature suggests 17%WW WW –– pooled risk of need for emergent repair 1.16% annuallypooled risk of need for emergent repair 1.16% annuallyAnnual risk of recurrence 1.9%Annual risk of recurrence 1.9%

Elective repair results in reduction of 0.13 Quality of Life Years Elective repair results in reduction of 0.13 Quality of Life Years

Watchful waiting preferred treatment in 83% of patientsWatchful waiting preferred treatment in 83% of patients

Paraesophageal Hernia Repair Mortality in Octogenarians

Poulose et al. J Gastrointest Surg 12:1888-1892, 2008

2005 National Inpatient Survey DatabaseParaesophageal Hernias

excluded congenital or traumatic 1005 patients1005 patients

30 day outcomesRecurrences/readmissions not evaluatedIncludes Open and Laparoscopic Operations

Paraesophageal Hernia Repair Mortality in Octogenarians

Poulose et al. J Gastrointest Surg 12:1888-1892, 2008

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Conclusions

Hernias are common and frequently encounteredMost abdominal hernias should be repaired

electively to avoid devastating complicationsWatchful waiting is appropriate in high riskWatchful waiting is appropriate in high risk

ASYMPTOMATIC patientsAll symptomatic hernias should be repairedMinimally Invasive Surgery offers improved

outcomes and quicker return to activities for all hernia repairs

THANK YOU

J. Scott Roth, MD