Bender Hernia[1]

8/8/2019 Bender Hernia[1]

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LAPAROSCOPIC INGUINAL

HERNIA REPAIR

Jeffrey S. Bender, MD, FACS

University of OklahomaCollege of Medicine


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Objectives

Appreciate the history and evolution

Understand the various approaches

Have knowledge of the complications and

outcomes

Not an attempt to teach how


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Inguinal Hernia The Problem

Very common

Recurrence rates still as high as 15%

Increased recognition that meshnecessary

Tension-free repairs


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Laparoscopic Hernia

Second most common laparoscopicprocedure

Initial enthusiasm now tempered

Technically more difficult than laparoscopic

cholecystectomy

Patient demand not as great


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History

First performed with clips 1979 (Ger)

Didnt become popular until laparoscopiccholecystectomy

Initial series (1990) reported plug only

Plug migration a problem: fixation


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History (cont)

Plug: recurrence rate of 25%

Realization that patch necessary

Recognition of defect in transversalis fascia

Three currently used techniques


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Transabdominal Preperitoneal

Herniorrhaphy (TAPP)

First reported 1991

Closure of peritoneum required

Easier to learn

Risk of bowel injury


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Intraperitoneal Onlay Mesh

Herniorrhaphy (IPOM) First reported 1992

Technically the easiest (no retro-peritonealdissection)

Anecdotal: adhesion of bowel to mesh

Not a problem in only large seriespublished


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Totally Extraperitoneal

Herniorrhaphy (TEPP) First reported 1993

Similar to Stoppa technique

Avoid bowel injuries

Learning curve reportedly more difficult


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Early Results

444 repairs in 375 patients, 1991-1994

Mostly TEPP; single surgeon

Recurrence rate 0.7%

Overall complication rate 2.0%

Two operations for SBO

FieldingAust NZ J Surg, 1995


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869 hernias in 686 patients, 1991-1992

TAPP, IPOM, multi-institutional

Recurrence rate 4.5%


One bowel perforation, one bladder injury, one SBO

Fitzgibbons, et al.Ann Surg, 1995

Early Results


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600 repairs in 493 patients, 1991-1994

TAPP, TEPP, single institution

Recurrence rate 1.2% (TAPP > TEPP)


3 bowel injuries, 2 bladder injuries, 1 SBO (port)

Ramshaw, et al.Surg Endosc, 1996

Early Results


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Effective repair

Probable shorter convalescence

No long term data

Serious complications in 2-4:1000

Summary of Early Results


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Randomized Trial #1

487 TEPP vs. 507 open, 1994-1995

One year follow-up

6 wound infections open vs. 0 in TEPP

(p=0.03)

TEPP had quicker recovery, back to work,

etc.


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Recurrence: 6.0% open vs. 3.0% TEPP (p=0.05)

24 conversions to open operation in laparoscopicgroup

7 major hemorrhage in laparoscopic group vs. 2in open group

Open operation not standardized (only 3% hadmesh)

Liem, et al.

NEJM, 1997

Randomized Trial #1


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496 laparoscopic vs. 460 open

One year follow-up

Complications: 29.9% lap vs. 43.5% open(p=.001)

Return to activity: 10 days lap vs. 14 daysopen (p=.004)

Randomized Trial #2


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Persistent groin pain: 28.7% lap vs. 36.7%

open (p=.018)

Recurrence: 1.9% lap vs. 0.0% open (p=.017)

3 major complications in laparoscopic group

MRC Group

Lancet, 1999

Randomized Trial #2


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989 laparoscopic (90% TEPP) vs. 994open, 1999-2001

Two year follow-up

Complications: 39.0% lap vs. 33.4% open

2 port site hernias, 2 major bleeds inlaparoscopic group

Randomized Trial #3


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3 deaths in laparoscopic group (1 bowelinjury)

1 death in open group

Return to activity: 4 days lap vs. 5 days

open

Laparoscopic had less pain

Randomized Trial #3


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Primary recurrence: 10.1% lap vs. 4.0% open

Recurrent recurrence: 10.0% lap vs. 14.1%

open, p=n.s.

250 lap hernias necessary to reduce recurrencerate

Open recurrence rate not altered by experience

Neumayer et al.

NEJM, 2004

Randomized Trial #3


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Summary

Laparoscopic herniorrhaphy likely less painful

Short term outcomes comparable

Long term outcomes unknown

Small, but real serious complication rate

Experience is key


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Documents

Bender Hernia[1]