Mesh Plug Repair of Inguinal Hernias. Presented by: V.K Ashok, M.D, F.A.C.S

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1 Mesh Plug Repair of Inguinal Hernias Presented by: V.K Ashok, M.D, F.A.C.S April 2, 2011

2 About V.K. Ashok, M.D Practicing general and vascular surgeon in private practice based in Freehold, NJ for the last 25 years Scope of practice includes specializing in inguinal and ventral hernias Most hernia operations performed in an outpatient setting Presently the Medical Director of Hernia Center

3 About The Hernia Center Established in 1986 by Drs. Robbins and Rutkow Serving the Greater New Jersey/New York area Perform approximately 350 inguinal hernia operations annually

4 No disease of the human body, belonging to the province of the surgeon, requires in its treatment, a better combination of accurate, anatomical knowledge with surgical skill than Hernia in all its varieties. Sir Astely Paston Cooper, 1804

5 Objective To demonstrate the benefits of the anterior open tension free repair of inguinal hernias

6 Outline Incidence of hernia Types of hernia Diagnosis Goals and types of hernia repair Types of mesh Post-operative recovery Complications Comparison of open vs. laparoscopic technique

7 Quick Facts on Hernias Most commonly done surgery in any operating room Approximately 770,000 operations done annually in the United States $2.5 billion annual cost for care of hernia patients Inguinal Hernia in the 21 st Century: An Evidence-Based Review Current Problems in Surgery, April 2008

8 Incidence Males: 27% in their lifetimes Men affected more than women (9:1) Femoral hernia incidence higher in women (4:1) Laparoscopic versus Open Inguinal Hernia Repair. Jon Gould, MD. Surgical Clinics of North America, April 2008

9 Types of Inguinal Hernias Direct Indirect Pantaloon Femoral

10 Diagnosis Clinical exam Imaging studies ultrasound CT scan MRI herniography

11 Goals of Hernia Repair To operate or not? Easy repair Minimal dissection Minimal post-operative pain Least amount of complications Rapid return to work Lower incidence of recurrence and reoperation

12 Types of Surgical Repair Open (anterior approach) Non mesh-based Halstead, Bassinni, McVay, Shouldice Mesh-based Lichtenstein, Plug and patch, PHS Laparoscopic (posterior approach) TEP TAPP

13 Tension Free Repair Concept began in the late 1980s/early 1990s 70% of all hernias are tension-free open repair Uses some type of mesh

14 Types of Mesh Used in Repair Lichtenstein Mesh plug Synthetic (Perfix, PHS, etc.) Absorbable - biologic Partially absorbable/ultrapro Lightweight Lightweight Perfix Plug and Patch Ultrapro Plug and Patch

15 Types of Anesthesia Used in Hernia Repair Local General Regional (preferred)

16 Open Anterior Approach - Mesh Plug Repair Short learning curve Shorter operating time Minimal dissection Tactile sensation Results are comparable to other types of repair

17 Operative Technique 5 centimeter incision

18 Operative Technique Use cautery for opening layers

19 Operative Technique Open inguinal canal and pick up cord structures at pubic tubercle

20 Operative Technique Dissect the sac free from cord structures

21 Operative Technique Invert the sac through deep inguinal ring

22 Operative Technique Deploy the plug at the defect

23 Operative Technique Place onlay patch on the floor of the inguinal canal with three point fixation

24 Operative Technique Begin closure of layers

25 Operative Technique Subcuticular closure of skin and use of steri-strips

26 Post-operative Recovery Resume normal activity immediately Working from home/self-employed: Next day Return to (office) work: 4 to 5 days Return to labor-intensive/ manual/construction work: 3 weeks Gym/sports activity: 4 weeks

27 Post-operative Pain Management Inject local anesthesia into wound Pain ball On-Q Oral analgesics

28 Complications Resulting from Open Hernia Repair Longstanding pain (uncommon) Hematoma, seroma Infection (superficial) Mesh removal (rare)

29 Open vs. Laparoscopic Technique Rate of recurrence is less Less time in the operating room Regional anesthesia Incidence of complications is less Return to work one day later Costs less to perform procedure Faster learning curve for trainees in surgery

30 Recurrence Less than laparoscopic More common amongst smokers and with those that experience weight gain Most recurrences are medial

31 Laparoscopic versus Open Inguinal Hernia Repair. Jon Gould, MD. Surgical Clinics of North America, April Recurrence Study Study done by Veterans Affairs 1983 veterans underwent open or laparoscopic inguinal hernia repair 2 year follow up completed in 85% of patients Recurrence more common in the laparoscopic group vs. open group (10.1% vs. 4.9%)

32 Operative Time and Recovery Study Study done by Dr. Rutkow at Hernia Center 4401 patients during a 15 year period between January 1989 and October (89%) primary hernias and 497 (11%) recurrent Average operative time was 24 minutes for primary and less than 30 minutes for recurrent 4120 (95%) returned to normal daily activity within 3 days, 98% by the end of week 1 The Perfix Plug Repair for Groin Hernias. Ira M. Rutkow, MD, MPH. Surgical Clinics of North America, 2003

33 Chronic Pain Study Study done at Chirurgische Praxiklinik Sauerlach, Germany Study of 300 patients with primary inguinal hernia repair with Ultrapro mesh No cases of chronic pain related to hernia repair nor a mesh-related complication Low Recurrence Rate in Hernia Repair Results in 300 Patients with Open Mesh Repair of Primary Inguinal Repair. Holzheimer, RG. European Journal of Medicine, January 2007

34 Cost Analysis Study Study done at Central Hospital, Sweden 1370 patients, 665 in the laparoscopic (TEP) and 705 in the open group Total hospital cost was Euros higher for laparoscopic repair Cost-minimization analysis showed that laparoscopic inguinal hernia repair had a small but significant increase in overall costs compared to open Long-Term Cost-Minimization Analysis Comparing Laparoscopic with Open Inguinal Repair. Eklund et. al., British Journal of Surgery, February 2010.

35 Conclusion Open mesh inguinal primary hernia repair can be safely performed with excellent success and good cosmetic results in patients in a specialized ambulatory clinic and is therefore an economic alternative for in-hospital treatment. Holzheimer, European Journal of Medicine The open technique is superior to the laparoscopic technique for mesh repair of primary hernias. Neumayer et. al., New England Journal of Medicine

36 Conclusion For primary unilateral inguinal hernia repair, open tension free repair with mesh is a cost-effective technique with low incidence of recurrence and complications and can be performed by most surgeons (and trainees) with ease.

37 Thank you for your attention! Contact Information: V.K. Ashok, M.D, F.A.C.S Phone: (732)

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