Chris Inguinal

INGUINAL HERNIA REPAIRActual Status

---------------------------------------

Prof. Dr. R.Van HeeUniversity of Antwerp

BelgiumEuropean Academy of Surgical Sciences

INGUINAL HERNIA REPAIR - ACTUAL STATUS (Abstract): Even in 2006, there are a lot of controversy about the best technique for inguinal hernia repair. The factors that influencethe choice of the technique are: uni- or bilateral hernia, “Nyhus” type of hernia, complicatedhernia, large inguino-scrotal hernia, recurrent hernia or previous surgery, preferred type of anaesthesia. Surgeon has to answer to three question when he choices a type of hernia repair: What are there specific indications for this repair? What are the specific complications of therepair technique? What are the results with the repair technique? In the literature there are a lot of studies which give comparisons about the techniques of hernia repair: type and rate of complications, recurrence rate, costs and economic impact. There are various types of evidence: retrospective studies, prospective randomized trials, meta-analyses. This paperreviews some of the literature studies about: techniques of open non-mesh hernia repair, typesof open mesh repair, mesh vs non-mesh open techniques, open vs laparoscopique techniquesand types of laparoscopic hernia repair techniques. Conclusion: Open non-mesh repairs shouldbe avoided. Lichtenstein mesh repair is the best open technique. Laparoscopic techniques (TAPP &TEP) induce: less pain, shorter hospital stay, earlier return to work, more rapidresumption of activities and lower recurrence rates but at a higher cost, especially in “non-working” population.

KEY WORDS: GROIN HERNIA, MESH REPAIR, TAPP, TEP

INGUINAL HERNIA REPAIR - ACTUAL STATUS (Abstract): Even in 2006, there are a lot of controversy about the best technique for inguinal hernia repair. The factors that influencethe choice of the technique are: uni- or bilateral hernia, “Nyhus” type of hernia, complicatedhernia, large inguino-scrotal hernia, recurrent hernia or previous surgery, preferred type of anaesthesia. Surgeon has to answer to three question when he choices a type of hernia repair: What are there specific indications for this repair? What are the specific complications of therepair technique? What are the results with the repair technique? In the literature there are a lot of studies which give comparisons about the techniques of hernia repair: type and rate of complications, recurrence rate, costs and economic impact. There are various types of evidence: retrospective studies, prospective randomized trials, meta-analyses. This paperreviews some of the literature studies about: techniques of open non-mesh hernia repair, typesof open mesh repair, mesh vs non-mesh open techniques, open vs laparoscopique techniquesand types of laparoscopic hernia repair techniques. Conclusion: Open non-mesh repairs shouldbe avoided. Lichtenstein mesh repair is the best open technique. Laparoscopic techniques (TAPP &TEP) induce: less pain, shorter hospital stay, earlier return to work, more rapidresumption of activities and lower recurrence rates but at a higher cost, especially in “non-working” population.

KEY WORDS: GROIN HERNIA, MESH REPAIR, TAPP, TEP

Inguinal Hernia Repair------------------------------

In 2006 :

Still much controversyStill many techniques

Hernia Repair: Historical Overview-------------------------------------------

• Eduardo Bassini (1844-1924): own technique 1877• Bassini modifications (Halsted,Kirschner,Houdard..)• Chester McVay (1911-1987): own technique 1948• Edward Shouldice (1890-1965): technique 1945-51• Lloyd Nyhus (°1923): type-related techniques 1955• Irving Lichtenstein (°1920): tension-free techn.1986

Hernia Repair: actual situation---------------------------------------

• Open techniquesShouldice repairLichtenstein repairPlug-mesh repairOther variants

• Laparoscopic techniquesTAPP repairTEP repairPlug repairOther variants

Factors influencing type of repair----------------------------------------

• Uni- or Bilateral hernia• “Nyhus” type of hernia• Incarceration of hernia• Large inguinoscrotal hernia• Recurrent hernia or Previous surgery• Preferred type of anaesthesia (patient/surgeon)• ……

Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]

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Choice of type of hernia repair---------------------------------------

• Which type does one use?• Are there specific indications for this repair?• Are there specific complications with this repair?• What are the results with this repair?

• ………..Why does one choose this type of repair?

“Evidence” concerning Hernia Repair----------------------------------------------1. Prolific number of clinical trials!!!2. Various types of evidence

-retrospective studies-prospective randomized trials-meta-analyses

3. Different end-points-type and rate of complications-recurrence rate-costs and economic impact

“Evidence” concerning hernia repair-------------------------------------------

• Often studies give comparisons between incomparable hernia groups:

a. mixing of uni- and bilateral herniasb. mixing of different Nyhus typesc. mixing of primary and recurrent herniasd. multicenter studies can be accompanied

by slight but important differences intechnique (mesh size, type, fixation etc.)

Trials in Open non-mesh Repair---------------------------------------

• Mostly before 1990• Comparing Bassini/Shouldice/McVay and other

techniques• Concluding evidence:

Shouldice technique is best repair, with a recurrence rate of ~5% after 2 years, but often raising to 10-15% after 10 years!

Results of Trials in Open mesh Repair

----------------------------------1. Lichtenstein repair (uni- or bilateral hernia)

-recurrence rate of <5%- less tension and pain

2. Stoppa repair (bilateral hernia)-recurrence rate ~ 1% after 6 years-needs general anaesthesia!

Trials comparing open mesh and non-mesh repair---------------------------------

Meta-analysis performed by the

EU Hernia Trialists Collaboration(Brit.J.Surg. 2000, 87: 854-859)

Conclusion: in favour of mesh repair1. Less pain 2. Earlier return to work3. Recurrences 1.4%’mesh) vs 4.4%(non-mesh)


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Types of trials comparingOpen and Laparoscopic techniques

• General trials: comparisons including multiple types of both techniques

• Specific trials: comparisons between single or specific techniques

• Meta-analyses: always including several types of techniques

General Trials: open vs lap--------------------------------

All open procedures vs. all laparoscopic procedures-on the short term lap techniques induce

1. earlier return to work2. less chronic pain3. variable rate of recurrences

P.J.O’DwyerBrit.J.Surg. 2004,70:105-118

General Trials: open vs lap technique--------------------------------

All open procedures vs. all laparoscopic procedures

-on the long term1. recurrences identical2. less chronic pain in lap techniques

P.J.O’DwyerBrit.J.Surg. 2004,70:105-118


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Specific trials: Fleming et al. Austr](BJS, 2001)

-------------------------Shouldice (n=115) vs TEP (n=117)-------------------------------------------

Endpoints were:-operation time (56 vs 70 min)-hospital stay (1-day:48 vs 68%) -sick leave (30 vs 14 days) - resumption of normal activities ( 35 vs 21 days) -costs (40% cheaper vs TEP) -complications at 1 year (9 vs 21%)

Specific trials: Champault et al.[Fr] (J.Chir.,1996)

--------------------Stoppa (n= 49) vs TEP (n= 51)------------------------------------

Endpoints were:- operation time (identical for unilateral;

shorter for bilateral Stoppa) - hospital stay ( 7.3 vs 3.2 days) - sick leave (35 vs 17 days),- postop. pain ( less in TEP) - recurrence (6% vs 2%)

Specific trials: Wara et al.[De](BJS, 2005)-------------------

Lichtenstein (n=39537) vs. TAPP (n=3606)-----------------------------------------------------

Endpoint: recurrence in various hernia categoriesprimary indirect: 1.0 % vs 0 %primary direct: 3.1 % vs 1.1%primary bilateral: 3.0 % vs 4.8 %recurrent unilateral: 4.8 % vs 4.6 %recurrent bilateral: 7.6 % vs 2.6 %

Specific trials: Eklund et al.[S]( BJS, 2006)------------------------

Lichtenstein (n=706) vs TEP (n= 665)----------------------------------------------

Endpoints were postop.pain, period of sick leave,and resumption of normal activities:

ALL 3 were in favour of TEP (p<0.001)-sick leave: 12 vs 7 days-normal activities : 31 vs 20 days

Size of mesh in TEP or TAPP--------------------------------------

Investigation in 10 cadavers to assess the size of a quadrangle, formed by the various hernia sites (inguinal, femoral, obturator, supravesical): mean surface of 71 cm².

Conclusion: mesh should at least measure10 x 8 cm to close all sites adequately!

Totté et al. Eur.Surg.Res.,2005.

Cost Aspect in Lap Surgery (TEP)-------------------------------------------

(Champault et al., J.Chir., 1994)

• Hospitalisation costs higher (105 Euro), even in case of reusable material

• Gain in sick leave and return to work howevergenerates a benefit of 160 Euro.

• Conclusion: TEP less costly only in case ofworking class population


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Conclusions----------------------

• 1. Open non-mesh repairs should be avoided• 2. Lichtenstein mesh repair : best open technique• 3. Laparoscopic techniques (TAPP &TEP) induce

-less pain, shorter hospital stay, earlier return to work, more rapid resumption of activities andlower recurrence rates, -but at a higher cost, specially in non-’working’population


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Chris Inguinal