inguinal hernia: future directions brian jacob md facs new york, ny

Inguinal Hernia: Future Directions

Brian Jacob MD FACS

New York, NY

Peter Drucker

• “The only thing we know about the future is that it will be different.”

November 1909 – November 2005. Influential author, businessman

Inguinal Hernia Repairs: innovation

Access

Mesh

Fixation

Patient Satisfaction

Techniques

Evolution of Inguinal Hernia: Access Techniques

Open

• Stromayr 1559• Lucas-Championnière

1881• Bassini 1889• McVay 1942• Shouldice 1945• Lichtenstein 1987• Stoppa 1989

Laparoscopic

• Ger 1990• Velez and Klein 1990• Others

SILS / NOTES

• Just now being described

1559 - 1989 1990-2008 2009 ---

Sachs M, Damm M, Encke A. 1997. World J Surg. 218-223

Early Inguinal Hernia Repairs

1559 Caspar Stromayr. Practica Copiosa.Great Ideas in the History of Surgery By Leo M. Zimmerman, Ilza Veith

Early Inguinal Hernia Repairs

1559 Caspar Stromayr. Practica Copiosa.Great Ideas in the History of Surgery By Leo M. Zimmerman, Ilza Veith

Inguinal Hernia: Emerging Technologies

• Single Port– Inguinal–Ventral

• NOTES– Transgastric– Transvaginal

Inguinal Hernia: Emerging Technologies

• Single Port– Inguinal–Ventral

• NOTES– Transgastric– Transvaginal

Indications

Inguinal Hernia: Emerging Technologies

• Single Port– Inguinal–Ventral

• NOTES– Transgastric– Transvaginal

Worse Options:

Single Incision Laparoscopic Surgery (SILSTM ): Introduction

• Descriptions as early as 1996• Synonyms

– SPA– LESS– Others

• Rapid growth since 2007

Single Incision Laparoscopic Surgery (SILSTM ): Introduction

• Rapid growth since 2007• Growth precedes proven clinical benefits

Single Incision Laparoscopic Surgery (SILSTM ): Introduction

• Rapid growth since 2007• Growth precedes proven clinical benefits• Demonstrated feasibility in multiple specialties

– General, Colorectal, Bariatrics, Urologic, and Gynecologic

Single Incision Laparoscopic Surgery: Many variations on a single theme

• Skin incision– Location and size

Single Incision Laparoscopic Surgery: Many variations on a single theme

• Skin incision– Location and size

• Entry method– Multiple trocars or single port access device

Single Incision Laparoscopic Surgery: Many variations on a single theme

• Skin incision– Location and size

• Entry method– Multiple trocars or single port access device

• Instrumentation / Scopes

Single Incision Laparoscopic Surgery: Many variations on a single theme

• Skin incision– Location and size

• Entry method– Multiple trocars or single port access device

• Instrumentation / Scopes• Retraction

SILSTM Inguinal Hernia: Introduction

• SILSTM TEP – Filipovic-Cugura J, Kirac I, Kulis T, Jankovic J, Bekavac-Beslin M

• (Surg Endosc April 2009) (Croatia) (routine)

– Jacob BP, Tong W, Katz B, Vine A, Reiner M• (Hernia June 2009) (USA) (SILSTM Port)

– Agrawal S, Shaw A, Soon Y• (Surg Endosc Sept 2009) (UK) (TriPort)

• SILSTM TAPP– Kroh M, Rosenblatt S

• (J Lap Adv Surg Tech A. April 2009) (USA) (Uni-X Single Port System)

– Rahman SH, John BJ• (Hernia. Aug 2009) (UK) (roticulating graspers)

– Menenakos C, Kilian M, Hartmann J• (Hernia. Aug 2009) (Germany) (TriPort)

Source: pubmed.gov as of October 5, 2009 (“single incision hernia”)

Question: What (if anything) is wrong with the current

standard?

Answer: Potentially only cosmesis

Early Experience: TEP

• Animal labs• 2 – 3mm instruments

– Still needed at least one 5 mm• Moved to 2 incision technique• Moved to single incision with multiple

trocars– Sword fighting– Air leaking

• Single port access device Feb 2009

Hernia. June 2009

Hernia. June 2009

Hernia. June 2009

Hernia. June 2009

SILSTM TEP:bilateral inguinal hernia repair

2 week follow-up

25 mm skin incision

SILSTM TEP:bilateral inguinal hernia repair

1 month follow-up

25 mm skin incision

SILSTM TEP:bilateral inguinal hernia repair

1 month follow-up

25 mm skin incision

SILSTM TEP:bilateral inguinal hernia repair

immediate post operative

SILSTM TEP: don’t celebrate too early

SILSTM TEP hernia:initial experience with a single access port

– 8 men with bilateral indirect hernias• One also with an umbilical hernia

– 1 man with unilateral indirect– 1 woman with b/l direct and femoral hernia

• 2 converted to traditional 3 trocars– Peritoneum violated– Inability to reduce an adherent indirect

SILS TEP hernia:initial experience with a single access port

– Mean follow-up 8 months• Incisional pain (1 - 6 days)• Narcotics used for 0 – 4 days• No early recurrences (up to 8 months)• No incisional hernias so far• Open umbilical hernia patient developed seroma

Early lessons learned

• Challenges– Port insertion has a learning curve

Early lessons learned

• Challenges– Learning curves all over again

Early lessons learned

• Challenges–Many ports available

• Are they needed at all?• Is one better than another?

Early lessons learned

• Challenges– Many ports available

• Are they needed at all?• Is one better than another?

– First trocar is blunt, but blind

Early lessons learned

• Challenges– Many ports available

• Are they needed at all?• Is one better than another?

– First trocar is blunt, but blind– Incision size

• Port modifications ARE needed

Early lessons learned

– Unknown outcomes• Seromas ?• Incisional Hernias ?• Costs ?• Let’s be realistic ?

SILSTM Inguinal Hernia: conclusions

• SILSTM TEP, TAPP, IPOM techniques now being described (feasible)– With and without single port access (SPA) devices

• Can be performed with same instruments in use today (may limit additional costs)

• Patients seem to like the single incision concept• Experiences are only in the beginning stages• Future is unknown

– Growth seems inevitable

Inguinal Hernia Repairs: innovationAcc

ess

Mesh

Fixation

Patient Satisfaction

Techniques

Randomized prospective Study of TEP: Fixation vs No Fixation of Mesh

• Jan 2002 – Jan 2004• 40 males underwent lap TEP followed for one year using

10-point VAS for pain followed for a mean of 9 months– (n=20) Heavyweight (100 g/m2) (Prolene) WITH TACKS– (n=20) Heavyweight (108 g/ m2) (Davol 3DM) WITHOUT fixation

• No significant difference in post op pain (p=0.15)• No significant difference in recurrent rates• Did see more urinary retention in group where tacks were

used

Koch CA, Greenlee SM, Larson D, Harrington JR, Farley DR. JSLS. 2006. (Mayo, Minnesota)

Randomized prospective Study of TEP: Fixation vs No Fixation of Mesh

• Conclusions– Use of tacks did not add pain (Is study under powered?)– Avoiding tacks did not change recurrence rates– Avoiding tacks can reduce costs, but keep outcomes the same

Koch CA, Greenlee SM, Larson D, Harrington JR, Farley DR. JSLS. 2006. (Mayo, Minnesota)

Laparoscopic inguinal hernia repair without mesh fixation, early results of a large

randomized clinical trial• Dec 2004 and Jan 2006• 360 males underwent lap TEP (500 hernias) followed for a

mean of 8.2 months. Pain scale used at office visit– Heavyweight (100 g/m2) (Prolene) WITH TACKS– Heavyweight (100 g/ m2) (Prolene) WITHOUT TACKS

• WITH TACKS group had more new pain complaints (p=0.0003)– No significant difference in recurrent rates

• Defect size all less than 2 cm• For bilateral patients, the NO TACK side was 5x more

likely to be more comfortable• Conclusion: tacks may increase pain, costs, and may not

be necessary– ? Better powered than the Mayo Clinic study

Taylor C, Layani L, Liew V etal. Surg Endosc. 2008. (Australia)

Laparoscopic TEP with nonfixation of the mesh for 1,692 hernias

• 3 year retrospective study– Followed for recurrences, pain at one month,

seroma, and urinary retention• Recurrence rate only 0.22%

– Less pain than a cohort of patients who received fixation

– Conclusions: TEP without mesh fixation does not increase recurrence rates and is associated with less pain, urinary retention at 4 weeks

Garg P, Rajagopal M, Varghese V, Ismail M. 2008. Surg Endosc. (Punjab, India)

Novel Concepts: Materials

• Self Adhering Mesh

• Fibrin Glues• Partially absorbing

mesh fibers• Absorbable Tacks

• Lightweight (40 g/m2) polypropylene coated with synthetic glue (adhesix)(cousin biotech, Fr)– Polyvinylpyrrolidone and polyethylene glycol– Disappears in 2 -3 days

• Porcine animal study• Same incorporation as mesh with tacks

Champault G etal. 2008 Hernia. (Paris, France)

Novel Concepts: Materials

• Self Adhering Mesh

• Fibrin Glues• Partially absorbing

mesh fibers• Absorbable Tacks

Novel Concepts: Materials

• Self Adhering Mesh• Fibrin Glues• Partially absorbing mesh fibers• Absorbable Tacks

• poly(glycolide-co-L-lactide) (PGLA).

Stepped Wing

Flat Wing

Want to entirely eliminate morbidity? Don’t operate

• New evidence to support watchful waiting until symptoms worsen without adverse events– Watchful Waiting vs Repair of Inguinal Hernia in

Minimally Symptomatic Men: A randomized clinical trial. Fitzgibbons RJ etal. JAMA 2006.

– Observation or Operation for Patients with an Asymptomatic Inguinal Hernia: A randomized clinical trial. O’dwyer PJ etal. Annals Surg. 2006

– Does delaying repair of an asymptomatic hernia have a penalty? Thompson JS etal. Am J Surg. 2008

Conclusions: inguinal hernia• Laparoscopic TEP / TAPP

– Recurrence rates not different in highly experienced hands– Chronic pain not sig different– May have early advantages for bilateral and recurrent hernias

• Lightweight mesh product – Less pain especially during first 3 months– Quicker return to work / activity – No difference in recurrence rates in experience hands

• Tack fixation may not be necessary if proper overlap of the myopectineal orifice is achieved

• Chronic neuropathic pain with early onset, that responds to nerve blockade (CRPS 2):– Best predictable outcome for relief following neurectomy or

meshectomy

Peter Drucker

• “The best way to predict the future is to create it.”

November 1909 – November 2005. Influential author, businessman

Thank you

bpjacob@gmail.com