Post on 07-Apr-2017
1
HERNIA SURGERY & ABDOMINAL WALL RECONSTRUCTION: time for change
2nd Europe conference, 2 – 4 Feb, 2017
Attenders and co-authors: Raimundas Lunevicius, Khalid Shahzad
Thanks to: Nikhil Misra, John Taylor
General Surgery Department Aintree University Hospital NHS Foundation Trust, Liverpool, England
14th Mar 2017
AWR 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
AWR 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
AWR Europe 2017
4
Requirements for successful hernia project
1. Decision & strong institutional support - is a key2. Dedicated faculty / consultants 3. Commitment for clinical & academic excellence4. MDT 5. Dedicated general surgeons6. Plastic surgeon7. Radiologist, anesthetist, etc.8. A wound-healing specialist9. ANP10. Clinic 11. Theatre with dedicated theatre staff12. Prospectively maintained database for independent data
managers / collectors / analytics
AWR 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
AWR 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
AWR 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
separation2. The preoperative progressive pneumoperitoneum
• with or without use of Botox type-A
AWR Europe 2017
8
Prosthetic materials: classification1. 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
AWR 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
AWR 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
AWR Europe 2017
© Bimal Kumar Kanhar, NGS
11
Hernia Disease: where the UK and England stands?
• Incidence
AWR Europe 2017
12
ASIR per female person-year in 20152,300 cases per 100,000 females in 2015, UK (95% UI 2,200 – 2,400) INCIDENCE of ventral hernia among females - HIGHEST IN THE WORLD
Abdominal wall hernia incidence. EpiViz, GBD 2015
13
ASIR per male person-year in 20156,000 cases per 100,000 males in 2015, UK (95% UI 5,600 – 6,600): Ventral hernia disease incidence among males is the HIGHEST IN THE WORLD in the UK
Abdominal wall hernia incidence globally. EpiViz, GBD 2015
14
The UK
AWR Europe 2017
15
ASIR per female person-year in 2015, UK2,800 cases per 100,000 females in 2015, UK (95% UI 2,700 – 2,900): North West region: HIGHEST INCIDENCE AMONG FEMALES
Abdominal wall hernia incidence: England, N. Ireland, Scotland, Wales. EpiViz, GBD 2015
16
ASIR per male person-year in 2015, UK6,400 cases per 100,000 males in 2015, UK (95% UI 5,900 – 7,000)
Abdominal wall hernia incidence: England, N. Ireland, Scotland, Wales. EpiViz, GBD 2015
17
Aintree University Hospital• Hernia surgery activities• Elective and emergency procedures combined
AWR 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 TotalIncisional hernia repair 16 6 14 8 80 124Umbilical/Periumbilical hernia repair 128 153 146 155 139 721Linea 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
ABI, 2017
AWR Europe 2017
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 124Umbilical/Periumbilical hernia repair 128 153 146 155 139 721Linea 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
ABI, 2017
AWR Europe 2017
21
Decline in hernia surgery procedures, Aintree
ABI, 2017
2012 2013 2014 2015 2016580
600
620
640
660
680
700
720
740
760
654
738
650
703
643
Grand total
2012 2013 2014 2015 20160
5
10
15
20
25
30
35
40
45
50
43.646.1
38.2
41.4
33.8
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)
AWR Europe 2017
23
A center 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 Thank you,Raimundas Lunevicius
Conclusions