Andy Maleachi TENSION FREE HERNIA REPAIR LICHTENSTEIN TECHNIQUE

Transcription

1 Andy Maleachi TENSION FREE HERNIA REPAIR LICHTENSTEIN TECHNIQUE

2 HENRY KISSINGER Soccer is a game that hides complexity in the appearance of simplicity How about inguinal hernia repair?

3 COMPLEXITY OF ANATOMY Although seemingly in innocuous operation & commonly performed, inguinal hernia repair done carelessly can result in significant complications. We should constantly remind ourselves of the complexity of the area & the ease with which the inguinal structures can be injured Arregui ME. Special Comment in Fitzgibbons Jr RJ and Greenburg AG, Editors : Nyhus amd Condon s Hernia, 5 th ed: , Lippincott Williams&Wilkins Co. 2002

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5 COMPLEXITY OF ANATOMY The complexity of dissections is increased by the varied patterns of nerve distribution Direct communications between branches of the major innervations Only approximately 20% of the patients have the normal pattern of sensory distribution Symetrical in only 40% of patients Rab M, Ebmer J, Dellon AL. Anatomic Variability of The Ilioinguinal and Genitofemoral Nerva : Implications for the Treatment of Groin Pain. Plast Reconstr Surg 2001;108:

6 COMPLEXITY OF CLASSIFICATION Groin Hernia Halvesson and McVay : 5 types Gilbert, Rutkow, Robbins : 7 types Nyhus : 4 types with 3 subtypes for type III and 4 subtypes type IV Bendavid TSD : 4 types with 3 stages & difference orifice dimension Schumpelick Aachen : 4 types with 3 grades of orifice size Unified classification : 9 types Zollinger Jr RM. Classifications of Ventral and Groin Hernia. Fitzgibbons Jr RJ : Nyhus and Condon s Hernia, 5 th ed:71-79, Lippincott Williams&Wilkins Co.2002

7 COMPLEXITY OF CLASSIFICATION The primary purpose of a classification system for any disease is to stratify for severity so that reasonable comparisons can be made between various treatment strategies. The disease severity bias can be put in as one of the causes of the contradictory results between some inguinal herniorraphy studies.

8 COMPLEXITY OF TECHNIQUES SELECTION Since the epoch making contributions of Bassini in 1888, no less than 81 inguinal & 79 femoral operative techniques have been described Bendavid R. New Technique in Hernia Repair. World J Surg 1989;13:522 =andyetitisstillimposibletodecidewhichone is the best

9 COMPLEXITY OF MESH SELECTION ISSUES : Monofilament Multifilament Non Absorbable Absorbable Large Pores Small Pores Heavyweight Lightweight Difference between thickness Difference between burst strength Coated Non Coated Biologic Mesh

10 COMPLEXITY Which classification? How to avoid post herniorraphy chronic groin pain? Which technique is the best for a given type of inguinal hernia? Is the one size fits all approach appropriate for inguinal hernia repair? Which mesh?

11 LICHTENSTEIN TECHNIQUE FOR INGUINAL HERNIA REPAIR Why it is chosen as one of the topics in this meeting? Can it still be used in the midst of the complexity?

12 The Lichtenstein Technique was first popularized by Lichtenstein in The routine use of mesh, coined the tension free repair took some time (about 10 years) to be universally adopted for primary hernia repair. Why so long? And how about its acceptance today?

13 WHY SO LONG? It is a natural way to face a change. It is not right to look at any change as meaning improvement, or motion as synonymous with advance. Advance means progress to something better & not progress to something new.

14 Certainly, in 1984 the Lichtenstein Technique was something new & it needed time to tell that this something new was truly something better. Now, 30 years afterwards, and after going through many RCT in many institutions, this technique clearly has withstood the test of time and evidently showed that it is something better.

15 European Hernia Society guidelines on the treatment of inguinal hernia in adult patients Hernia (2009) 13: DOI /s

16 Elective Surgery Primary unilateral Primary bilateral Recurrent Mesh recommendation: Lichtenstein or Laparoscopic Mesh recommendation: Laparoscopic or Lichtenstein After anterior technique After posterior technique Mesh technique Laparoscopic or open posterior approach Mesh technique Lichtenstein Laparoscopic surgery (TEP preferred to TAPP) if expertise present

17 HOW GOOD? Low recurrence Easy to learn Easily applied in most settings Chronic groin pain?

18 HOW GOOD? Low Recurrence - Lichtenstein Hernia Institute began in 1984 Slightly modified in : 5360 hernias in 4360 patients 1000 bilateral hernias 360 recurrence hernias 6 recurrences Amid PK, Lichtenstein IL. Aktuelle Einschatzung der Spannungsfrein Hernienreparation nach Lichtenstein. Der Chrurg 1997;68:959-64

19 HOW GOOD? Low Recurrences Advantage : Decrease the incidence of compared with sutured repair hernia recurrence EU Hernia Trialist Collaboration. Mesh compared with non mesh methods of open groin hernia repair : Systematic review of randomized controlled trials. Br J Surg 2000;87:854-9 Butter M, Redecke J, Koninger J. Long term result of randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs. Br. J Surg 2007;94:562-5 Van Veen RL et al. Long term follow up of a randomized clinical trial of non mesh bersus mesh repair of primary inguinal hernia. Br J Surg 2007;94:506-10

20 As the causes of early recurrence after hernia repair were eliminated (faulty technique, ignorance of the functional anatomy & physiology of the abdominal wall, the use of incorrect suture material, infection), it become apparent that a percentage of hernias will recur over the years because of factors beyond the control of the surgeon

21 These are mainly the natural weakening of the tissues and deterioration of body fitness with time & agung, increased adiposity, raised intra abdominal pressure owing to chronic cough, constipation, & obstructive disease of the urinary bladder. This problem of aging is one of the reasons why reinforcement using a prosthetic mesh in hernia repair is needed.

22 HERNIA Unbalanced distribution of collagen types I (mature, high-tensile strength) & III (immature, low-tensile strength) Ajabmour MA, Mokhtar AM, Rafee AA, et al. Defective collagen metabolism in Saudi patients in hernia. Ann Clin Biochem. 1992; 29: Friedman DW, Boyd CD, Norton P, et al. Increases in type III collagen gene expression and protein synthesis in patients with inguinal hernias. AnnSurg.1993;218: Henriksen NA, Yadete DH, Sorensen LT, Agren MS, Jorgensen LN. Connective tissue alteration in abdominal wall hernia. Br J Surg 2011;98:210-19

23 Difference in extracellular matrix IMMUNOHISTOCHEMICAL ANALYSIS OF THE COMPONENT OF THE EXTRACELLULAR MATRIX Control Stable Scar Incisional Reccurent Hernia Incisional Hernia Tenascin (Skin) Tenascin (fascia) Fibronectin (skin) Fibronectin (fascia)

24 DIFFERENCE IN EXTRACELLULAR MATRIX IMMUNOHISTOCHEMICAL ANALYSIS OF THE COMPONENT OF THE EXTRACELLULAR MATRIX Control Stable Scar Incisional Reccurent Hernia Incisional Hernia MMP-1 (Skin) MMP-1 (fascia) MMP-13 (skin) MMP-13 (fascia) Collagen 1/3 (skin) Collagen 1/3 (fascia)

25 The disorder of the collagen metabolism might explain as well the success of surgical meshes inducing an inflammatory foreign body reaction with a consecutive, intense fibrosis resulting in a compound of nonabsorbable mesh filaments as a mechanical-sealing mechanism & an embedding collagen-rich scar tissue. Both components form the mechanical stable artificial abdominal wall. Consequently, hernia patients showing a defect in forming stable scar tissue will finally need a mesh repair.

26 Country Year Types of inguinal hernia repair Conventional Open Laparoscopic Other (%) mesh (%) (%) (%) Netherlands Denmark ,5 82,5 15 Finland France , ,6 Poland Austria Hungary Sweden , PROVIDED BY THE WORKING GROUP

27 HOW GOOD? Low Recurrences The mesh application from the internal side of the abdominal transversalis fascia (posterior approach) is more physiologic than the anterior approach (Lichtenstein). But as long as the Lichtenstein technique is rightly done (good overlap, good fixation) it does not really matter in respect to the rate of recurrence.

28 GOOD OVERLAP Anterior Approach Failure of hernia repairs nearly always occur laterally of the mesh-tissue interface because of failure of fixation, incorporation, or lack of overlap

29 GOOD OVERLAP Anterior Approach Amid The mesh should extend 2 cm across the pubic tubercle, 3-4 cm above conjoined tendon and 5-6 cm lateral to the internal ring New Development in Hernia Repair. Voeller GR. Surgical Technology International XI, 2003

30 HOW GOOD? Easy to learn Neumayer L, Gobbie Hurder A, Jonasson O, Fitzgibbons Jr R, Dunlop D, Gibbs J, Reda D, Henderson W. Open Mesh Versus Laparoscopic Mesh Repair of Inguinal Hernia. N Engl J Med 2004;350: Multicentre Study, 14 VA Medical Centres, 1695 patients, two years follow up, Lichtenstein technique was used

31 RECURRENCE RATE, PRIMARY HERNIA Laparoscopic Group Less experienced ( repairs): 12,3% Highly experienced (>250 repairs) : 5,1% Lichtenstein Group Less experienced ( repairs) : 2,5% Highly experienced (>250 repairs) : 4,1% Not significantly different (p=0,12)

32 HOW GOOD For most surgeons, a Lichtenstein technique onlay repair is easy to learn & easily applied in most setting (e.g. it can be done under local anesthesia) It has been studied more than the other open mesh repairs in randomized trials across multiple institutions such that the results from these large studies can be generalized to both the general population and the typical general surgeon Wood B, Neumayer L. Open repair of inguinal hernia : an evidenced-based review. Surg Clin N An 2008;88:139-55

33 POST HERNIORRAPHY CHRONIC GROIN PAIN In recent years, emphasis has shifted toward evaluation of the patient s quality of life after surgical intervention and relief of symptoms, with presence of inguinal pain viewed as an end point in evaluating hernia surgery. This emphasis is of particularly importance, if a patient is undergoing herniorraphy to reduce inguinal pain, it would be disservice to cause undue pain secondary to improper groin dissection.

34 Hernia repair is not a simple procedure but one requiring precise skill & judgment to give the patient a repair that is not only durable but also enjoyable Cunningham J. The physiology and anatomy of chronic pain after inguinal herniorraphy. In Fitzgibbon RJ, Greenburg AG. Hernia 5 th ed. Lippincott Williams&Wilkins. Philadelphia 2002.

35 CHRONIC GROIN PAIN Nerve injury during dissection Nerve injury during fixation Nerve entrapment by scar Injury to pubic tubercle Mismanagement of the acute post-operative pain Type of the mesh

36 Chronic groin pain is the most often a result of nerve injury sustained during improper dissection FerzliGS,EdwardE,AlKhouryG,HasdinRM.Posthernioraphygroinpainandhowtoavoidit. Surg Clin N Am 88(2008):

37 NERVE INJURY Issues : preserve no preservation prophylactic neurectomy therapeutic neurectomy

38 It did not matter if the surgeon had identified & protected the nerve, divided the nerve, or simply ignored the nerved all had the same incidence of chronic pain The nerve encasement by scar is probably a more common cause of chronic pain than direct injury to the nerve Cunningham J. The physiology and anatomy of chronic pain after inguinal herniorraphy. In Fitzgibbons RJ, Greenburg AG. Hernia 5 th ed. Lippincott Williams&Wilkins. Philadelphia 2002

39 PROPHYLACTIC NEURECTOMY Lichtenstein IL, Schulman AG, Amid PK, et al. Cause and prevention of postherniorraphy neuralgia: a protocol for treatment. Am J Surg 1988;155: Mui WL, Ng CS, Fung TM. Prophylactic ilioinguinal neurectomy in open inguinal hernia repair : a double blind randomized controlled trial. Ann Surg 2006; 244:27-33

40 REMAIN CONTROVERSIAL Other studies have failed to demonstrate a statistically significant difference in incidence of postoperative pain between nerve division versus preservation Pappalardo G, Frattarolli FM, Mongardini M, et al. Neurectomy prevent persistent pain after inguinal herniorraphy : a prospective study using objective criteria to asses pain. World J Surg 2007;31:1081-6

41 The most crucial preventive step to reduce the incidence of postoperative groin pain is careful dissection & preservation of the ilioinguinal, iliohypogastric, and genitofemoral nerves. It has been demonstrated that when all three nerves are identified & preserved, no cases of chronic pain were identified at 6 month follow up. Alfieri S, Rotondi F, di Giorgio A, et al. Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorraphy: prospective multicentric study of chronic pain. Ann Surg 2006:243:533-8

42 To date, evidence suggests that the best prevention for this morbidity is avoiding inguinal nerve injury. All measures should be taken to ensure meticulous technique & careful dissection, with particular attention to avoiding incorporation of the inguinal nerves into stitches. FerzliGS,EdwardE,AlKhouryG,HardinRM.Postherniorraphygroinpainandhowtoavoidit. Surg Clin N Am 88 (2008):

43 REDUCING THE RISK 1. Avoiding removal of the cremasteric muscle fibers 2. Avoiding indiscriminate division of subcutaneous tissue 3. Avoiding extensive dissection of the ilioinguinal nerve 4. Identifying & preserving all neural structures 5. Avoiding making the inguinal ring too tight 6. Avoiding placement of suture in the lower edge of the internal oblique muscle Amid PK. Causes, prevention, and surgical treatment of chronic pain after inguinal herniorraphy. In Fitzgibbons RJ, Greenburg AG. Lippincott Williams and Wilkins, 2002.

44 CONNECTION BETWEEN TYPE OF MESH AND POSTHERNIORRAPHY CHRONIC GROIN PAIN Since 1980, a gradual incease in the routine use of mesh in the inguinal space during hernia repair has occurred. The additional fibroblastic stimulus caused by the polypropylene type meshes added a fibrotic entrapment mechanism to the list of causes of postoperative inguinal pain Geiss WP, Singh K, Gillian GK. An algorithm for the treatment of chronic pain after inguinal herniorraphy. In Fitzgibbons RJ, Greenburg AG. Lippincott Williams and Wilkins, 2002.

45 Mismanagement of the Acute Post-operative Pain

46 Traditionally, pain has been defined as acute or chronic-that is, pain that lasts for a short time, or pain that continues or recurs for a longer period But this division is not perfect Acute pain can become chronic if left untreated and chronic pain can have acute exacerbations or flare-ups

47 A current concept of pain centers around neuronal plasticity Neurons detecting and transmitting pain display plasticity (the capacity to change function, chemical profile or structure, which contributed to altered sensitivity to pain)

48 In the normal pain response, pain intensity increases as the stimulus intensity increases

49 Sensitization following injury causes the pain response (curve) to shift to the left, resulting in hyperalgesia, in which noxious stimuli cause greater and more prolonged pain, as well as allodynia, in which pain results from normally painless stimuli Sensitization is the manifestation of neuronal plasticity

50 PAIN SENSITIZATION

51 CLOSING It can be seen that although the Lichtenstein technique has many advantages, it also has its own inherent risk of complications. As Bendavid stated, there are many techniques for inguinal hernia repair, but one another also has its advantages and disadvantages, so it is impossible to decide which technique is the best.

52 It suffices to say that the surgeon should master a single technique for the vast majority of inguinal hernia repairs, to maximize proficiency and to minimize its complications, and also one to two additional technique which may be required in different clinical scenario

53 He should use existing experimental and clinical data to estimate long term benefits of any new prosthetic and any new technique. Change is in evitable and change is generally good, but change just for the sake of change is not

54 Thank You For Your Patience