HERNIA MANAGEMENT
| LAPAROSCOPIC vs OPEN INGUINAL HERNIORRHAPHY—Robert J. Fitzgibbons, Jr, MD, Harry E. Stuckenhoff
Professor of Surgery, Creighton University School of Medicine, Omaha
|
| Laparoscopic repair: preperitoneal procedures (transabdominal preperitoneal [TAPP] and totally extraperitoneal [TEP])
more common than intraperitoneal procedure
|
| Open (Lichtenstein) repair: involves exposure and mobilization of space between external oblique aponeurosis and underlying
internal oblique muscle
|
| Literature review: most studies show benefit of laparoscopic repair over open repair; Picchio et al—105 patients randomized
to TAPP or open repair; open repair shown to be better procedure; TAPP repair longer to perform; less pain in open-repair
group on day 2; 16 most commonly quoted studies—all studies that looked at analgesia use, pain scores,
complications, time to recovery, return to work, quality of life, and recurrences showed improvements with laparoscopic repair,
compared to open repair; 46% showed less complications with laparoscopic repair; 3 updated studies show less long-
term pain and numbness with laparoscopic repair; Cochrane Review—laparoscopic repair has same recurrence rate as
open tension-free repair; laparoscopic repair associated with less postoperative pain (immediate and late) and earlier return
to normal activities, but longer to perform, more expensive, and higher risk for serious complications
|
| Veterans Affairs Cooperative Studies Program 456: study design—multisite (14 sites), prospective, randomized trial
comparing laparoscopic repair (TAPP or TEP) to Lichtenstein open repair; 3-yr enrollment and minimum follow-up of 2 yr;
results—recurrence rate at 2 yr for open group 4%, compared to 10.1% for laparoscopic group (statistically significant);
overall, intraoperative and immediate postoperative complication rates worse for laparoscopic group; long-term complication
rate similar for both groups; 30-day and 2-yr mortality similar for both groups; 4 deaths attributed to herniorrhaphy (1
pulmonary embolism, 1 myocardial infarction, and 1 intestinal injury in laparoscopic group, and 1 bowel obstruction secondary
to femoral hernia in open group); patient-centered outcomes—laparoscopic group had statistically significant improvements
in perception of pain and average pain at rest on day of surgery and at 2 wk during normal activities, work, or
exercise; high levels of pain on day of operation and at 2 wk in open group; long-term pain similar for both groups; laparoscopic
group returned to activities sooner and performed more activities at 2 wk; surgeon experience—for laparoscopic
group, high recurrence rate until surgeon had performed >250 cases; low experience found to be <250 cases; large variability
in recurrence rate for laparoscopic repair, depending on site and surgeon who performed operation; multivariate
analysis—laparoscopic repair had 2.6 times increased risk for intraoperative complication; open repair had 1.5 times increased
risk for chronic pain
|
| Bittner et al meta-analysis: 34 trials involving 7000 patients who underwent laparoscopic (TAPP, TEP) or Lichtenstein
open repair; laparoscopic repair associated with decreased incidence of wound infection, hematoma, and nerve injury,
less chronic pain, and earlier return to normal activities; laparoscopic repair took longer to perform and had increased
rates of recurrence and seroma formation
|
| When to perform laparoscopic hernia repair: recurrent hernia; bilateral hernia; with other simultaneous laparoscopic procedure;
inguinodynia; complicated hernia cases
|
| TREATMENT OF VENTRAL HERNIAS—Dr. Fitzgibbons
|
| Zollinger classification of ventral abdominal wall hernias
|
 | Congenital: omphalocele; gastroschisis; infant umbilical
|
| Acquired: midline—diastasis recti; epigastric; adult-type umbilical and paraumbilical; median—supravesical; paramedian
(interparietal; spigelian)
|
| Incisional: midline; paramedian; transverse; special operative sites, eg, parastomal
|
| Traumatic: penetrating; blunt; destructive
|
| European Hernia Society (GREPA) definition of incisional hernia: any abdominal wall defect, with or without bulge,
perceptible either by clinical examination or imaging study
|
| Classification parameters: location—vertical, transverse, or oblique (above or below umbilicus); size—<5 cm, 5 to 10 cm,
or >10 cm; primary or recurrent—if recurrent, primary or multiply recurrent; reducibility—if not reducible, presence
or absence of obstruction; symptoms—presence or absence
|
| Causes of incisional hernia: poor surgical technique; rough handling of tissue; use of rapidly degraded absorbable suture
material; tension; infection; predisposing factors—male sex; older age; morbid obesity; abdominal distention; pulmonary
disease; cigarette smoking; malnutrition; hyperalbuminemia; malignancy; jaundice; steroids; chemotherapy
|
| Principles of surgical practice: transverse and oblique incisions have lower rate of hernia and dehiscence; upper midline
incisions have highest rate of herniation; muscle-splinting procedures reduce wound complications, but restrict access to
abdomen; Hodgson et al—ideal wound closure uses nonabsorbable sutures and continuous technique; suture sinuses
and wound pain significantly lower with absorbable sutures
|
| Conventional incisional herniorrhaphies: simple nonprosthetic repair—“vest over pants” (fascia imbricated layer upon
layer) and simple apposition procedures achieve poor results (recurrence rate 30% to 70%) and should be used only for
simplest hernia repairs; Ramirez component separation technique involves incision lateral to rectus muscle and separation
of internal and external muscles, with transversalis fascia allowing rectus muscle to be advanced; prosthetic onlay
technique—prosthesis placed on top of simple repair, with or without primary closure; prosthetic bridging
technique—if fascia cannot be closed, peritoneum closed first, then mesh placed over open defect; achieves better results
than prosthetic onlay technique, but recurrence rate significant; combined fascia and mesh closure—involves
opening anterior rectus sheath around wound, creating flap of anterior rectus sheath that can be sutured to create stronger
retrorectus fascial layer; anterior defect closed with mesh; achieves better results than onlay procedure; Flament (sublay)
technique—gold standard; prototype retrorectus operation; anterior rectus sheath opened and flap formed from posterior
rectus sheath, then space developed beneath rectus muscle to anterior axillary line on either side of midline (for midline
defect); sutures placed lateral using suture-passer techniques and mesh pulled in to pocket; fascia closed in midline posteriorly
and closed over defect, regardless of tension, to achieve better cosmetic result
|
| Laparoscopic techniques: laparoscopy can be used for small ventral hernias, but conventional repair more suitable; suture
passer—used in all laparoscopic procedures to put full-thickness suture in abdominal wall; suture pulled through small
skin incision, then brought back out through same skin incision but separate fascial incision and tied on outside; knot can be
dropped into subcutaneous tissue, allowing suture to be placed and exclude skin; when treating larger defects, need to be
very lateral and use multiple cannulas; speaker uses three 5-mm cannulas and one 10-mm cannula and moves them to maximize
angles; important for mesh to be flush with abdominal wall
|
| OTHER METHODS OF INGUINAL HERNIA REPAIR—Dr. Fitzgibbons
|
| Conventional anterior nonprosthetic procedures: Marcy—simplest operation; involves closing internal ring medial to
core structures at internal ring; primarily used for small hernias in pediatric and adolescent patients; Bassini—prototype
operation; initial incision more often made transversely, as opposed to oblique incision in past; external oblique aponeurosis
divided over inguinal canal through external ring; division and resection of cremasteric muscles can result in testicular
descent, so speaker advocates splitting cremasteric muscles; full-length division of inguinal floor indicated; high
ligation of indirect sac synonymous with simple inversion of sac back into preperitoneal space; routine resection of inguinal
scrotal hernia sacs associated with increased incidence of testicular atrophy via disturbance of venous plexus that
drains testicle; indirect inguinal sacs should be divided in inguinal canal, leaving distal sac in situ; relaxing incisions employed
in many operations by dividing anterior rectus sheath; Maloney darn—prototype mesh operation; involves conventional
operation followed by placement of lattice of back-and-forth sutures, simulating mesh; Shouldice—involves
development of 4 layers for closure of inguinal floor; transversalis fascia completely open, then 4 layers developed medially
to suture to 4 pseudoshelves of inguinal ligament; Shouldice surgeons report excellent results since 1940s; McVay Cooper’s
ligament repair—rarely used but useful for femoral hernias, infected wounds, and incarcerated femoral hernias
|
| Conventional anterior prosthetic procedures: plug and patch—first described by Gilbert; present system popularized by
Bard; gaining in popularity, but speaker rarely uses it
|
| Issues with mesh repairs: carcinogenesis—no case report of humans developing mesh-related carcinoma; Schumpelik
has described sarcomatous changes in rats fitted with polypropylene meshes; infertility—meshes, especially polypropylene,
can erode into spermatic cord; unilateral repair can cause sterility because mesh erosion into cord structures
and sperm extravasation can cause patients to develop sperm antibodies, which can cause infertility
|
| Conventional anterior preperitoneal prosthetic procedures: Read-Rives—conventional groin exploration performed
and posterior floor opened; mesh placed beneath inferior epigastric vessels through anterior approach; Stoppa, Wantz,
Nyhus, and Condon approaches—more common than anterior approach; incision made above groin and preperitoneal
space entered posteriorly; Kugel and Ugahary approaches—hybrid laparoscopic-conventional operation; large prosthesis
placed through preperitoneal space through very small internal ring incision; technically difficult
|
| LAPAROSCOPIC MANAGEMENT OF PARAESOPHAGEAL HIATAL HERNIA -– Nathaniel J. Soper, MD, Professor
and Vice-Chair, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago
|
| Hiatal hernia classification: type I—sliding hiatal hernia; abdominal viscus makes up part of hernia sac; medial borders of
hernia sac are walls of stomach; type II—uncommon; gastroesophageal (GE) junction at or below diaphragm; type III—
paraesophageal hiatal hernias; combination of type I and II; accounts for relatively low percentage of all hiatal hernias, but
increasing in incidence as population ages and increases in size; 4 times more common in women; mean patient age >60 yr
|
| Presentation: variable; patient may be asymptomatic and identified by finding of air behind heart on chest x-ray; symptoms—
postprandial fullness, distress, or retching; shoulder pain; dysphagia; typical reflux symptoms; anemia, which may be related to
gastric ulcers (Cameron’s erosions) that occur where lip of stomach passes up through hiatus; respiratory symptoms (dyspnea,
pneumonia); hypothesized that occasionally stomach may press on lungs, causing dyspnea; gastric obstruction (volvulus) with
strangulation may occur, which has high mortality rate
|
| Diagnostic evaluation: perform barium swallow or upper gastrointestinal (GI) radiography on all patients to evaluate GE
junction and hernia morphology and determine presence of organoaxial volvulus of stomach; perform endoscopy to
check for mucosal disease and esophageal manometry to assess preoperative motility; speaker does not believe 24-hr pH
test required preoperatively
|
| Laparoscopic repair technique: divide sac at esophageal hiatus; reduce completely into abdomen and excise most of sac;
completely mobilize distal esophagus by going up into mediastinum and lengthen esophagus if necessary; close crura
with sutures (bioprosthesis used if tension present); perform fundoplication; anterior gastropexy occasionally performed,
particularly if patient has preoperative organoaxial volvulus, because of potential for postoperative subdiaphragmatic
volvulus; important to identify and avoid anterior and posterior vagus nerves; may need to go up 10 to 12 cm to mobilize
esophagus to get adequate intra-abdominal length; speaker uses braided sutures for crural closure and tries to incorporate
peritoneum on both sides; uses pledgets if hole big or tension present; speaker avoids plastic mesh; close posteriorly initially
because 2 crura almost parallel and relatively close together, allowing most of defect to be brought together without
tension; fundoplication varies depending on preoperative esophageal motility, but Nissen is default procedure; speaker
tries to close crura so they touch walls of empty esophagus
|
| Study data: 116 patients; majority female; mean age 65 yr; 4 patients transferred in acutely with incarcerated hernias; majority
type III hiatal hernias; 10% of patients thought asymptomatic; 3 patients aborted; 98% of patients underwent laparoscopic
repair, of whom 6 required lengthening procedure; mean operating time 3 hr; length of stay ranged from overnight to 18
days (median 2 days); time to return to work or full activity 2 wk; complication rate 17%; 2 early reoperations required (1 for
perforation, 1 for postoperative vomiting); mortality 2% (both cases due to myocardial infarction after discharge, but within
first month after surgery); barium swallows performed and hiatal abnormality seen in 22%, of which 4 were true recurrent
paraesophageal hernias, remainder being small type I hernias, and majority asymptomatic; reoperation rate 3%
|
| Recurrence after laparoscopic repair: University of Southern California (USC) study—recurrence rate 40% (most asymptomatic
and diagnosed after barium swallow); Allegheny study—routine postoperative barium swallows performed in
166 patients; 5% had recurrent paraesophageal hernia; 20% had type I hiatal hernia postoperatively; Montreal study—
retrospective review comparing open and laparoscopic repair; higher recurrence rate with open repair than laparoscopic repair
|
| Controversies in repair of paraesophageal hernias: hernia sac—speaker does not advocate simply dividing sac and leaving
in thorax, because being outside of sac allows better visualization for dissection, and mesothelial-lined peritoneum increases
chance of developing fluid collections postoperatively; prosthetic material for closure of hiatus—Frantzides et
al showed no recurrences when Gore-Tex patches used at hiatus; speaker does not advocate use of Gore-Tex as patches
can erode into esophagus; antireflux procedures—no good data; in elderly patients, speaker often inserts percutaneous
endoscopic gastrostomy (PEG) tube to decompress stomach postoperatively, which may prevent recurrence
|
Educational Objectives
| The goal of this program is to educate the listener about hernia management. After hearing and assimilating this program,
the clinician will be better able to:
|
| 1. Contrast laparoscopic and open repair of inguinal hernias.
|
| 2. Treat incisional hernias.
|
| 3. Discuss methods of inguinal hernia repair.
|
| 4. Evaluate paraesophageal hernias.
|
| 5. Employ laparoscopic techniques in the management of paraesophageal hernias.
|
Suggested Reading
Amid PK: Groin hernia repair: open techniques. World J Surg 29(8):1046, 2005; Andujar JJ et al: Laparoscopic repair of
large paraesophageal hernia is associated with a low incidence of recurrence and re operation. Surg Endosc 18(3):444,
2004; Arvidsson D et al: Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice
repair of primary inguinal hernia. Br J Surg 92(9):1085, 2005; Bay-Nielsen M et al: Chronic pain after open mesh and sutured
repair of indirect inguinal hernia in young males. Br J Surg 91(10):1372, 2004; Bickel A et al: Laparoscopic repair of
paracolostomy hernia. J Laparoendosc Adv Surg Tech A 9(4):353, 1999; Bittner R et al: Comparison of endoscopic techniques
vs Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled
trials. Surg Endosc 19(5):605, 2005; Carlson MA et al: Ventral hernia and other complications of 1,000 midline
incisions. South Med J 88(4):450, 1995; Diaz S et al: Laparoscopic paraesophageal hernia repair, a challenging operation:
medium-term outcome of 116 patients. J Gastrointest Surg 7(1):59, 2003; Ferri LE et al: Should laparoscopic paraesophageal
hernia repair be abandoned in favor of the open approach? Surg Endosc 19(1):4, 2005; Hashemi M et al: Laparoscopic
repair of large type III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll Surg 190(5):553,
2000; Hodgson NC et al: The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg
231(3):436, 2000; Korenkov M et al: Classification and surgical treatment of incisional hernia. Results of an experts' meeting.
Langenbecks Arch Surg 386(1):65, 2001; McCormack K et al: Laparoscopic techniques versus open techniques for
inguinal hernia repair. Cochrane Database Syst Rev (1):CD001785, 2003; Motson RW: Why does NICE not recommend
laparoscopic herniorraphy? BMJ 324(7345):1092, 2002; Muldoon RL et al: Lichtenstein vs anterior preperitoneal prosthetic
mesh placement in open inguinal hernia repair: a prospective, randomized trial. Hernia 8(2):98, 2004; Neumayer LA
et al: Proficiency of surgeons in inguinal hernia repair: effect of experience and age. Ann Surg 242(3):344, 2005; Neumayer
L et al: Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350(18):1819, 2004;
Oelschlager BK et al: The use of small intestine submucosa in the repair of paraesophageal hernias: initial observations of
a new technique. Am J Surg 186(1):4, 2003; Schmedt CG et al: Comparison of endoscopic procedures vs Lichtenstein and
other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc
19(2):188, 2005; Shin D et al: Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable
cause of obstructive azoospermia. Ann Surg 241(4):553, 2005; Stylopoulos N et al: Paraesophageal hernias: operation or
observation? Ann Surg 236(4):492, 2002; Valenti G et al: The Marcy repair modified using cremaster muscle sparing. A
new and effective method for performing prosthetic hernioplasty. Surg Today 35(8):645, 2005; Zollinger RM Jr: An updated
traditional classification of inguinal hernias. Hernia 8(4):318, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Fitzgibbons was recorded March 17, 2005, at the Postgraduate Course in General Surgery sponsored by the University
of California, San Francisco, School of Medicine and held in San Francisco. Dr. Soper was recorded June 15,
2005, at Advances in Gastrointestinal and GI Laparoscopic Surgery sponsored by the University of Minnesota Medical
School and held in Minneapolis. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
|
