Ing hernia open vs lap ahm 2013 sept
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Transcript of Ing hernia open vs lap ahm 2013 sept
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
[email protected] 1Herniacon Ahmedabad 12-15 Sept, 2013
Medical DirectorNova Medical Centers Pvt Ltd, India
Consultant SurgeonMinimal Access and Bariatric SurgeryNova Specialty Surgery, Koramangala & Manipal Hospital, Bangalore
Greetings From….
Dr. M G BhatMS, FRCS(England), FRCS ( Edinburgh), FICSDMLE (Law), DMIRCSEd (Informatics)
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
[email protected] 2Herniacon Ahmedabad 12-15 Sept, 2013
Inguinal Hernia
Open Hernia RepairIs this the end of the Road?
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
[email protected] 3Herniacon Ahmedabad 12-15 Sept, 2013
Inguinal Hernia - epidemiology
• Very Common• Life Time Risk: % : 27 M :3 F • >20million Repairs/yr/worldwide• 100-300 / 100000 / yr• 100,000 in UK /yr• 800,000 in US• Approx > ?? in India /yr
1. Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835-9.2. Kingsnorth AN, LeBlanc KA. Management of abdominal hernias. 3rd ed.London, New York: Edward Arnold, 2003:40-7.3.Samir S A, Shawn P F .Current Approach to Inguinal Hernia Repair. Am J Surg 2004;188-6;9-164. Richard Burnley: http://online.epocrates.com/u/2942723/inguinal+hernia 2012 Dec: BMJ Content
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Treatment Options .1
Acute: Irreducible, Strangulated, Obstructed or Uncertain viability of the bowel
Open:
Preferred Approach by most Surgeons
Lap:
Few Published Reports
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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• Paper Based of the review of literature: 43 articles found: • 16 reported use of Lap • 7 reported exclusive use of Laparoscopy • and were fully reviewed.
• 328 cases• 6 Conversions• Average Stay 4 days• 34 Complications ( Mostly Minor)• 17 Resections ( by lap or mini laparotomy)
Laparoscopic Approach to Incarcerated and Strangulated Inguinal Hernia: S Deeba, E Zacharakis et all. JSLS(2009)13:327-331
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Treatment Options .2
Large or Symptomatic Hernia
Open:
Preferred Approach by most Surgeons
Lap:
Preferred-on the expertise the Surgeon
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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• Size and Type of Hernia
• Technical Capability• Access to Facility• Previous Operations• Cost factors
What Repair ? How to select ?
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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What techniques in 2013>>>>?
• 95% Open Mesh- Lichtenstein• 5% Laparoscopy
EU Hernia Trialists Collaboration Laparoscopic compared with open methods of groin hernia repair:systematic review of randomized trials. Br J Surg 2000;87:860-7. ….And Many other Publications
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Repair Types used in USA (as of 2003)
Procedure Total & (%)
Lichtenstein 229500 (37)
Plug 227000 (34)
Laparoscopy 111500 (14)
Other meshes
65000 (8)
Tissue Repairs
55000 (7)
SS Awad, SP Fagan. Current Approaches to Inguinal Hernia Repair. Am J Surg;2004;188-6;9-16
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Treatment Options .3
Recurrent or Bilateral Hernia
Lap:
Preferred Approach. To be doneby Lap Surgeons
Open:
Done by All otherSurgeons
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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• Laparoscopy safe, comfortable, cost effective
What is Best for – Bilateral ?
A prospective German Study- Schmedt CG, Daubler P, Leibl BJ, Kraft K, Bittner R. Simultaneous bilateral laparoscopic inguinal hernia repair. Surg Endosc. 2002;16:240-244
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Recurrent Hernia..?
• Following Open- Lap
• Following Lap - Open
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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80 yrs/M with IHD and Respiratory Problems ..
What Repair?
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Treatment Options .4
High Surgical Risk Patients
Open:
Preferred Approach Under Local Anesthesia
Lap:
Not suitable For GA
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Which is Better - Open or Lap ?
N Engl J Med 2004;350:1819-27. (www.nejm.org)Prospective Random Study comparing- Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia. Neumayer L, Giobbie-Hurder A, Jonasson O, et all. for the Veterans Affairs Cooperative Studies Program 456 Investigators
• Lap - Pain Less • Lap – Early Return to Work
• But Higher Risk of Serious Complications and Recurrence
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Open Hernia ..When?
• Large Hernia• Complicated Hernia• Lap Recurrent Hernia• Previous Surgery ?
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Lap Hernia ..When?
• Fit Patients• Uncomplicated Hernia• Bilateral & Recurrent• Cost Factor??
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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2004 revised recommendations….• Lap repair to be considered for first time management of unilateral inguinal hernias
2001 Recommendation…. • Open Mesh Repair preferred approach for primary hernia• Laparoscopy for Recurrent and Bilateral Hernia
NICE (National Inst for Clinical Excellence, UK)
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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National Institute of Health and Excellence(NICE Guidelines) UK
TA83Hernia laparoscopic surgery (review) (TA83)
Technology appraisals TA83 Issued: September 2004
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Laparoscopic surgery can be used as an option for repairing inguinal hernia.
As with all surgery, there are some risks involved, which may include serious problems just after the operation, pain or numbness in the area of the operation, and the hernia coming back.
Your doctor should tell you about the risks and benefits of each of the types of surgery (open surgery, or laparoscopic surgery using either the TAPP or TEP methods) before you make a decision on which method to have.
NICE ….
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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In helping you make this decision you and your doctor should particularly consider: 1. How well you are likely to cope with a general anesthetic2. First or Recurrent3. Unilateral or Bilateral 4. Open or Lap is the best 5. Surgeons Experience
NICE has also said that laparoscopic surgery for inguinal hernia repair by TAPP or TEP should only be performed by specially trained surgeons who regularly carry out the procedure.
NICE ….
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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BMJ. 2003 May 10;326(7397):1012-3.
Prospective randomized controlled trial of lap vs open
Both with good long term results & low recurrence
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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The Surgeon FactorThe Surgeon Factor
The Surgeon isThe Surgeon is the most important the most important
prognostic factor.prognostic factor.
The Skills and Experience of the The Skills and Experience of the Surgeon are more important than the Surgeon are more important than the type of repair.type of repair.
Wantz,Hernia,1994Wantz,Hernia,1994
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Treatment Options .5
Operate or Not in Hernia ?
• Very High Surgical Risk Life Expectancy Limited Refuse Repair
Small & Asymptomatic Hernia
Can Consider WatchfulWaiting
Can Consider WatchfulWaiting
Safer to Avoid !
Safer to Avoid !
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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NICE Guidelines 2004
With seemingly similar results and complications the choice between the two procedures should firmly be based on the surgeon’s experience and preference
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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POEM is the present Philosophy…•Patient
•Oriented •Evidence that •Matters
Patient-Oriented Evidence that Matters(editorial BMJ 2002;325:983)www.infoPOEMs.com/informationmastery.cfm
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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http://dx.doi.org/10.1136/bmj.f3795 (Published 11 June 2013) BMJ 2013;346:f3795
News: BMJ June 2013Surgeons Performance data to be available from July
Inguinal Hernia Open Vs. Lap © 2012 NOVA SPECIALTY SURGERY
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Thank you