Laparoscopic inguinal hernia repair

Transcription

1 Abdominal wall M. Miserez, F. Muysoms Leuven, Gent Warm-up Package Eighth edition Strasbourg, April 7, 2011 Laparoscopic inguinal hernia repair

2 Inguinal hernia treatment: factors to consider Recurrence Quality of life postoperative recovery, chronic pain Safety risk for perioperative complications Learning curve grade of difficulty/reproducibility Cost hospital and society costs Let us then speak the same language Hernia classification Outcome parameters

3 The EHS Groin Hernia Classification > 2 fingers indirect direct 1 finger 1-2 fingers femoral The EHS guidelines on the treatment of inguinal hernia in adult patients Simons et al, Hernia 2009; 13:

4 Topics Risk factors/prevention Diagnostics Indications for treatment Classification Treatment General Bilateral Recurrent Laparoscopy: TAPP vs TEP Women Young men (18-30) Biomaterials Simons et al, Hernia 2009; 13: Topics Training/specialist centers Complications (excl recurrence) Chronic pain Antibiotic prophylaxis Anesthesia Day Surgery Postoperative pain control Postoperative recovery Aftercare Costs Simons et al, Hernia 2009; 13:

5 1a 1b 2a 2b 2c 3a 3b Levels of evidence Oxford Centre for Evidence-based Medicine Levels of Evidence (2001) systematic reviews of RCTs individual high quality RCT Recommendation A systematic reviews of cohort studies individual cohort study or low quality RCT outcomes research B systematic reviews of case-control studies individual case-control study 4 case-series and poor quality cohort and casecontrol studies C 5 expert opinion D Which techniques are necessary to learn during surgical residency? 1. Lichtenstein 2. TEP 3. TAPP 4. Stoppa 5. Shouldice

6 Treatment: All male adult (>30 years) patients with a symptomatic inguinal hernia should be operated on using a mesh technique. The open Lichtenstein and endoscopic inguinal hernia techniques are recommended as the best evidence-based options for repair of a primary unilateral hernia providing the surgeon is sufficiently experienced in the specific procedure. Grade A Mc Cormack et al, 2005 Schmedt et al, 2005 Lichtenstein hernioplasty Lichtenstein and Shulman, Int Surg 1986

7 Endoscopic groin hernia repair large prosthesis with reinforcement of the whole myopectineal orifice ~ minimally invasive STOPPA repair (GPRVS) Chirurgie, 1973; 99: Flow diagram treatment

8 Endoscopic vs Lichtenstein FU > 48 months Recurrence ± 5% Postoperative recovery It is recommended that an endoscopic technique is considered if a quick post-operative operative recovery is particularly important. Grade A

9 Treatment : chronic pain Endoscopic mesh techniques result in a lower chance of chronic pain/numbness numbness than Lichtenstein. In the long-term (> 3-43 years FU), these differences seem to decrease for the aspect pain, but not for numbness. Level 1B Treatment chronic pain It is recommended that risks of development of chronic postoperative pain are taken into account when the method of hernia repair is decided upon Grade B lower age (level 2A) preoperative groin pain (level 2B) preoperative chronic pain conditions (level 2B) female gender (level 2B)

10 Minimally invasive surgery is there to stay But Treatment Endoscopic hernia techniques vs. Lichtenstein repair result in a Longer operation time (8-13min), Higher incidence of seroma Level 1A Need for general anesthesia Mc Cormack et al, 2005 Schmedt et al, 2005

11 Costs It is recommended that, from a hospital perspective, an open mesh procedure is used for the treatment of primary unilat.. inguinal hernia. From a socio-economic perspective, an endoscopic procedure is proposed for the active working population, especially for bilateral hernias Grade A How to reduce hospital costs Reusable instruments Trocars Fixation devices (selective) Ambulatory surgery

12 Endoscopic surgery: long and steep learning curve Treatment: Complications laparoscopy There appears to be a higher rate of rare but serious complications with endoscopic repair, especially during the learning curve period Level 2B

13 Training: the learning curve The learning curve for performing endoscopic inguinal hernia repair (especially TEP) is longer than for open Lichtenstein repair, and ranges between 50 and 100 procedures, with the first being most critical Level 2C Learning curve errors in laparoscopic surgery Not (longer) tolerated

14 The learning curve depends also on the structure of the training program! A learning curve is far from a straight progression The most important variables in the learning curve Structured training program Laparoscopic experience of the trainee Patient selection No recurrent or scrotal hernia No previous appendectomy for right sided hernia Female patient Type of supervision Mentoring vs proctoring Expertise and motivation of the trainer

15 Groin hernia: endoscopic repair TAPP (Transabdominal Preperitoneal) more easy to learn - endoscopic suturing transperitoneal approach higher risk for postoperative intestinal obstruction Duron et al, Arch Surg 2000 Bringman and Blomqvist, Hernia 2005 laparoscopic exploration TEP (Totally ExtraPeritoneal) more difficult to learn anatomy more difficult to understand limited working space preservation of peritoneal integrity safer? laparoscopic exploration also easily possible Be familiar with the anatomy! indirect inguinal hernia Groin hernia: anatomic aspects genital branch of genitofemoral nerve falx inguinalis conjoint tendon direct inguinal hernia pubic symphysis inguinal ligament (Poupart) lacunar ligament (Gimbernat) TRIANGLE OF PAIN TRIANGLE OF DOOM ramus superior ossis pubis = pectineal ligament obturator artery femoral hernia

16 Systematic TEP inguinal hernia repair in 10 consecutive steps Miserez et al, Surg Lap Endosc Percut Tech Introduction of first trocar 2. Introduction of second trocar 3. Dissection to Bogros space and introduction of third trocar 4. Reduction of direct inguinal hernia 5. Reduction of femoral/obturator obturator hernia 6. Reduction of indirect inguinal hernia 7. Lateral dissection and reduction of preperitoneal lipoma 7 Contralateral dissection 8. Preparation and introduction of the mesh 9. Placement of the mesh and fixation in selected cases 10. Desufflation Desufflation basic advanced

17 20 years old male unilateral symptomatic inguinal hernia left side right side positive on ultrasound, clinical examination?, no symptoms 1. unilateral TAPP 2. bilateral TAPP 3. unilateral TEP 4. bilateral TEP 5. other 40 years old female unilateral femoral hernia, minimal symptoms 1. unilateral TAPP 2. unilateral TEP 3. bilateral TAPP or TEP 4. Lichtenstein 5. wait and see

18 80 years old male ASA III unilateral nonreducible inguinoscrotal hernia, symptomatic 1. unilateral TAPP 2. unilateral TEP 3. unilateral Lichtenstein 4. wait and see 50 years old male oral anticoagulants for CVA bilateral inguinal hernia symptomatic 1. bilateral TAPP 2. bilateral TEP 3. bilateral Lichtenstein 4. wait and see

19 70 years old male recurrent hernia after TEP symptomatic 1. TAPP 2. retep 3. Lichtenstein 4. wait and see 45 years old female incarcerated inguinal or femoral hernia 1. TAPP 2. TEP 3. open approach 4. laparoscopy and open repair 5. laparoscopy and laparoscopic repair (TAPP or TEP)

20 Treatment: laparoscopy TAPP vs. TEP For endoscopic inguinal hernia techniques, TAPP seems to be associated with higher rates of port-site hernias and visceral injuries while there appear to be more conversions with TEP Level 2A TAPP TEP open Vascular injuries Visceral injuries 0.13% 0% 0% 0.65% 0.16% 0.14% Memon et al, Br J Surg 2003 McCormack et al, Health Technology Assessment 2005 Treatment: laparoscopy TAPP vs. TEP It is recommended that an extraperitoneal approach (TEP) is used for endoscopic inguinal hernia operations Grade B

21 Our personal vision you do the best what you do the most posterior approach: laparoscopic (tep) anterior approach: lichtenstein Laparoscopic ventral and incisional hernia repair

22 Introduction Did you perform laparoscopic ventral/incisional hernia repair yourself? 1. No 2. < 5 cases cases 4. > 10 cases Introduction What is your preferred technique for open incisional hernia repair? 1. Onlay 2. Inlay 3. Sublay retromuscular 4. Underlay

23 Mesh positioning X? IPOM = intraperitoneal onlay = underlay! Mesh positioning: the gold standard? retromuscular (Rives-Stoppa) Rives et al, Bordeaux Med 1976; 26: 2115 Stoppa, World J Surg 1989; 13: 545

24 Laparoscopic vs. open: arguments pro minimal abdominal wall tissue trauma less hematoma, seroma, wound infection prosthetic infection? cosmetic benefit shorter hospital stay, better recovery less postoperative pain easier exploration of the whole scar less recurrences ± 5%?? Laparoscopic vs. open: arguments con extensive adhesiolysis necessary prolonged ileus 2%?? missed or delayed enterotomy, postoperative peritonitis, mesh infection & removal, mortality no reconstruction of the abdominal wall mesh bridging recurrence vs. bulging cave lightweight mesh mesh augmentation

25 Laparoscopic vs. open: arguments con long-term effects of intraabdominal mesh and fixation devices intestinal obstruction intestinal erosion and fistulisation more expensive prosthetic materials antiadhesive capacities (chronic) infection risk chronic pain long-term follow-up necessary (min. 3 years) transfascial sutures and/or fixation devices? chronic seroma formation ~ retention of hernia sac trocar site hernias 1. Onlay mesh bridging 2. Onlay mesh augmentation 3. Inlay mesh (= interposition) 4. Sublay mesh bridging 5. Sublay mesh augmentation 6. Underlay mesh bridging (= IPOM) 7. Underlay mesh augmentation muscles/anterior rectus sheath mesh posterior rectus sheath/peritoneum

26 Meshes and fixation devices Polypropylene most commonly used many different products Pro macroporous (type I) mostly monofilament high tensile strength mechanically stable optimal tissue ingrowth good tolerance to infection Con very rigid not to be used in contact with viscera

27 Polyester (polyethylene( polyethylene) Mersilene (Ethicon)) and Parietex (Covidien) Pro macroporous optimal tissue ingrowth softer than polypropylene Con multifilament (type III) ~ increased harvesting of bacteria not to be used in contact with viscera hydrolytic disintegration over years (esp. in case of persisting infection) Expanded polytetrafluoroethylene (eptfe) Pro flexible, soft, nonfraying high tensile strength mechanically stable can be used in contact with viscera easily visible on ct-scan (foto dubois) Con microporous multifilament (type II) less intense tissue ingrowth (encapsulation) more shrinkage secure permanent fixation necessary need for removal when infected (hydrophobic)

28 Type I Type II Type III Type IV Classification of biomaterials totally macroporous > 75µ totally microporous < 10µ (in at least one of the 3 dimensions) macroporous with multifilamentous or microporous components submicronic pore size (only used in composite materials for adhesion prevention) pores > 75µ needed for admission of polymorphonuclear leucocytes (> 10µ), macrophages ( ( 50µ), fibroblasts, blood vessels and collagen fibers into the pores total removal of the type II prosthesis and at least partial removal of the type III prosthesis is required in order to manage infection (bacteria = 1µ) 1 Amid, Hernia 1997; 1: 15 Lightweight or not? Current polypropylene meshes are likely to be too strong and too rigid Foreign body reaction too pronounced

29 Lightweight or not: weight versus pore size Pore size Macroporous (> µm) vs. megaporous (> µm) Textile porosity vs. effective porosity (% pores > 1000µm diameter) Weight or density > 80 g/m 2 < 40 g/m 2 Surface area Lightweight or not? Resulting mesh characteristics Tensile strength Uniaxial load testing Load per unit width (N/cm) Load per unit surface (N/cm 2 ) Biaxial ball-burst testing Mesh elasticity Testing in different directions for anisotropic meshes Cobb et al, Hernia 2009

30 Tensile strength requirements Maximal abdominal pressure: 20 kpa (=150 mmhg) Mesh augmentation Thin walled ball FD D r 16N/cm Mesh bridging Thin walled cylinder D L l 32N/cm Maximal abdominal wall tensile strength: 82N/cm (horizontal) 32N/cm (vertical) Klinge et al, Chirurg 1996 Klinge et al, World J Surg 2005 Closure of the defect? Closure percutaneously or via minilaparotomy Nonresorbable monofilament suture Less seroma Less bulge Not more chronic pain Chelala et al, Surg Endosc 2007 Small defect (<5x5cm) not needed Large defect (>7x7cm) difficult/impossible Intermediate defect or ellipsoid defect

31 Mesh elasticity most important in vertical direction Junge et al, Hernia 2001 Early dislocation of a too light mesh?

32 The ideal mesh for intraabdominal use Optimal tissue incorporation/remodelling at the parietal side (macroporous) No or minimal adhesion formation at the visceral side (microporous) Easy handling capacities Transparent and a bit sticky Low cost Tissue separating meshes (1): bioabsorbable barriers Hydrophilic collagen-polyethylene glycol-glycerol glycerol coating polyester Parietex Composite polypropylene Parietene Composite Sodium hyaluronate + carboxymethylcellulose (Seprafilm ) polypropylene Sepramesh Absorbable barrier for 7-10 days Sufficient? Oxidized regenerated cellulose (ORC) polypropylene Proceed (light weight) Omega 3 fatty acid polypropylene C-Qur (Lite) (light weight)

33 Tissue separating meshes (2): composite meshes/coated meshes eptfe polypropylene Composix Composix E/X Composix L/P (lightweight) DualMesh Tissue separating meshes (3): eptfe 20-22µ < 3µ corduroy surface DualMesh Plus antimicrobial agents: silver chlorhexidine DualMesh Plus with Holes macropores for faster tissue attachment

34 How to choose? A A lot of (often( conflicting) animal data No RCT comparing only two different mesh materials No human clinical studies needed for FDA approval/ce marking Mesh half life is often (very) short Retrospective data on mesh complications Few data on relook laparoscopies N=85 Chelala et al, Hernia 2010 Neoperitoneum perfectly covering the mesh No shrinking or wrinkling of the mesh

35 How to choose? Caveat eptfe mesh component in case of (potential) contamination secure permanent fixation necessary when using full eptfe Laparoscopic ventral/incisional hernia repair Fragile antiadhesive barrier Bulky mesh when rolling Lightweight mesh for bridging large defect Transparence, memory, abdominal wall adhesive capacity Adequate dimension or easy to be cut without loosing antiadhesive properties Cost! Mesh fixation: what to use? 1. sutures 2. fixation devices 3. combination of both 4. glue

36 Mesh fixation: what to use? sutures non-resorbable (slowly) resorbable fixation devices single crown double crown Carbajo et al Morales-Conde et al? Combination Glue to cover fixation devices and mesh edges? to diminish the number of fixation devices? Fixation: sutures + fixation devices full thickness transparietal sutures slowly resorbable accurate orientation and placement of the mesh additional fixation first 3-4 weeks minimising the risk for chronic pain at least 4 - every 6cm careful grasping of the suture enough tissue incorporation (1-1.5cm) 1.5cm) nonresorbable sutures in case of full eptfe mesh

37 LVHR: fixation devices titanium (n=30) Protack Sorbafix absorbable 5mm absorbable 5mm AbsorbaTack Tensile strength and adhesion formation to fixation systems Absorba Tack and SorbaFix are resp. solid and hollow screw tacks, completely resorbed after one year

38 Parietene Composite - Absorbatack Tensile strength and adhesion formation to fixation systems Hollinsky et al, Surg Endosc 2010 Rat model Parietex Composite mesh Prolene suture

39 What about pain? Kumar Bansal et al, Surg Endosc 2011 Protack Polypropylene RCT, laparoscopic repair, majority polypropylene mesh But Wassenaar et al, Surg Endosc tacks + tacks

40 Fixation: sutures + fixation devices fixation devices every 2cm and at least 1cm from the edge of the mesh avoid recurrence between mesh and abdominal wall! double crown technique to reduce dead space to increase tissue ingrowth deep enough ( peritoneum or preperitoneal fat) external counterpressure! extra 5mm trocar contralaterally if needed

41 10 RCT Almost 1000 patients Large heterogeneity in the different trials Clinical Hernia size/location Surgical technique Open: onlay, sublay fascial closure Laparoscopic: mesh overlap mesh fixation = IPOM Learning curve effect

42 Large heterogeneity in the different trials Methodological randomisation process (primary outcome parameter) Operation time Results too heterogenous to be pooled

43 Complications Any complication Major vs. minor complications Minor Minor Wound infection Seroma formation: problem of definition Hematoma Acute and chronic pain Major (Missed) enterotomy Mesh removal Reoperation Mortality

44 Enterotomy recognised and unrecognised No results extractable on ICU admission No mortality (described) Hematoma-seroma

45 Seroma vs. open mesh placement Wound infection

46 Wound infection vs. open mesh placement Hospital stay Significantly shorter in 6/9 trials But large heterogeneity

47 Hospital stay Short-term term pain

48 Hernia recurrence 0% 3.3% 0% Follow-up > 2 years in only 3 trials

49 EBM based conclusions Large heterogeneity in the different trials Laparoscopic incisional hernia repair Is safe Benefit of decreased wound infections and shorter hospital stay No increased recurrence rates with medium-term follow-up The key to succes is a careful adhesiolysis and avoiding/immediate treatment of enterotomy No decrease in acute pain My personal conclusions Excellent indication in Obese patients diabetics Lateral hernias Parastomal hernias rectus muscle Beware for patients with Wide hernias or a diffuse bulge Hernias close to bony edges: extraperitoneal mesh Careful patient selection in learning curve Eg. umbilical hernia/trocar site hernia in obese patient Exploration of the whole scar posterior rectus sheath/peritoneum Miserez and Penninckx, Surg Endosc 2002; 16: