Hernia: Laparoscopic vs. Open Repair Michael R. Renfrow M.D., F.A.C.S. Clinical Assistant Professor, Dept. of Surgery, Florida International University Objectives Examine the anatomy and pathophysiology of a hernia Identify patients who are candidates for surgical intervention Evaluate current and emerging surgical options (open, laparoscopic, robotic) for patients with a hernia Hernia Abdominal wall composed of: -skin -subcutaneous tissue (fat) -muscle -fascia (hernia is a hole in the fascial layer) -peritoneum (hernia sac) A hernia is defined as sac formed by the lining of the abdominal cavity. The sac comes through a hole or weak area in the strong layer of the abdominal wall called the fascia. 1
www.medicalook.com400 www.dreamstime.com400 artmiller.medicalillustration.co 2
Types of Hernia Umbilical Inguinal Ventral/Incisional Spigelian Femoral Hiatal/Paraesophageal Obturator mdvaldosta.hubpages.com www.healthtap.com 3
www.gastrohep.com herniaonline.com steveblank.com 4
Risk Factors Increased intra-abdominal pressure Obesity COPD Heavy lifting Tobacco/Smoking Genetic (Collagen) Previous abdominal surgery (Incisional hernia) Signs and Symptoms Pain (dull, worse on exertion) Bulge or mass Differential Dx Hernia Lymph Node (Reactive, Metastatic, Lymphoma) Soft tissue tumor (Lipoma, Sarcoma) Vascular (tumor, anuerysm) Cyst Desmoid, Endometrioma (female patient, hx of a gynecologic surgery, close to the scar) Hydroceale/Varicoceale Testicular Torsion Testicular Tumor 5
Diagnostic Imaging Ultrasound (Dynamic with Valsalva) CT scan MRI www.radiopaedia.com www.healthtap.com 6
www.madisonradiologists.com Management Observation (Abdominal binder) Surgical Repair -Laparoscopic vs Open -Mesh Principles of Hernia Surgery Safely reduce hernia content (bowel, omentum, etc ) Excise hernia sac Close fascial defect Minimize tension on the repair Reinforce with mesh when indicated 7
Laparoscopic vs Open Hernia Surgery Which repair is better? What are the differences between the two? Laparoscopic vs Open Approach Open Anterior approach Traditional incision Laparoscopic Posterior approach Multiple small incisions Open Comparing Surgical Technique Open Repair is an anterior approach Laparoscopic Repair is a posterior approach www.netterimages.com 8
www.netterimages.com www.netterimages.com 9
www.urologycentre.com 10
universitysurgicalconsultants.com www.webmedcentral.com 11
Inguinal Hernia Laparoscopic vs. open No significant difference in recurrance rate Data suggests less pain and numbness in laparoscopic repair Return to usual activities is faster in laparoscopic repair Operative times are longer with laparoscopic Higher risk of serious complication with laparoscopic approach, in particular bladder and vascular injury Cocharane Database Syst Rev 2003(1) Ventral/Incisional Hernia Laparoscopic vs. Open No difference in recurrence rate Reduced risk of wound infection in laparoscopic Shortened hospital stay Lower 30-day morbidity in laparoscopically repaired strangulated & recurrent hernias (4.7%vs8.1%) No difference in pain intensity -Cochrane Database Syst Rev 2011 Mar 16(3) -Ann Surg 2011 Oct;254(4):641-52 12
Paraesophageal & Hiatal Hernia Protrusion (or herniation) of the upper part of the stomach into the posterior mediastinum via a disruption of the esophageal hiatus of the diaphragm Symptoms: Heartburn, Chest pain, Cough Management: Medical management (PPI) Surgery (Open, Laparoscopic, Robotic) 13
14
15
References Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial. Pokorny H, Klingler A, Schmid T, Fortelny R, Hollinsky C, Kawji R, Steiner E, Pernthaler H, Függer R, Scheyer M. Hernia. 2008 Aug;12(4):385-9. doi: 10.1007/s10029-008-0357-1. Epub 2008 Feb 19. PMID: 18283518 [PubMed - indexed for MEDLINE] Related citations Remove from clipboard Select item 14703756 Inguinal hernia: an old condition with new solutions. Nathan JD, Pappas TN. Ann Surg. 2003 Dec;238(6 Suppl):S148-57. Review. PMID: 14703756 [PubMed - indexed for MEDLINE] Related citations Remove from clipboard Select item 20454807 Laparoscopic inguinal hernia repair: gold standard in bilateral hernia repair? Results of more than 2800 patients in comparison to literature. Wauschkuhn CA, Schwarz J, Boekeler U, Bittner R. Surg Endosc. 2010 Dec;24(12):3026-30. doi: 10.1007/s00464-010-1079-x. Epub 2010 May 8. Review. PMID: 20454807 [PubMed - indexed for MEDLINE] Related citations Remove from clipboard Select item 23552714 Laparoscopic versus open anterior abdominal wall hernia repair: 30-day morbidity and mortality using the ACS-NSQIP database. Mason RJ, Moazzez A, Sohn HJ, Berne TV, Katkhouda N. Ann Surg. 2011 Oct;254(4):641-52. doi: 10.1097/SLA.0b013e31823009e6. PMID: 21881493 [PubMed - indexed for MEDLINE] Related citations Remove from clipboard Select item 23296600 Laparoscopic vs. open incisional hernia repair: a randomized clinical trial. Eker HH, Hansson BM, Buunen M, Janssen IM, Pierik RE, Hop WC, Bonjer HJ, Jeekel J, Lange JF. JAMA Surg. 2013 Mar;148(3):259-63. doi: 10.1001/jamasurg.2013.1466. PMID: 23552714 [PubMed - indexed for MEDLINE] Related citations Remove from clipboard Select item 21412910 Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007781. doi: 10.1002/14651858.CD007781.pub2. Review. PMID: 21412910 [PubMed - indexed for MEDLINE] Related citations Remove from clipboard 16