5/5/2010 1 Hernias: Who, What, When, Where, Why? J. Scott Roth, MD Chief, Gastrointestinal Surgery Director, Minimally Invasive Surgery University of Kentucky June 16, 2009 Objectives Identify patients at risk for hernias Understand the etiology and pathophysiology of hernias Review the demographics of patients with hernias Discuss common hernia locations and associated signs and symptoms Understand why (or why not) a hernia should be repaired Provide an overview of techniques for hernia repair and associated controversies Common hernia types Inguinal Hernia Hernia: The protrusion of an organ or other bodily structure through the wall that normally contains it; a rupture. Inguinal: Of, relating to, or located in the groin. Myopectineal Orifice of Fruchaud MPO Superior- arched fibers of int. oblique Inferior – iliac bone Medial – rectus abdominis m. Lateral – iliopsoas & iliopectineal arch Hesselbach’s Triangle
15
Embed
51 Hernias Roth.ppt - UK HealthCare · PDF file5/5/2010 2 Inguinal Hernia U.S. Abdominal Hernia Repairs 2003 Inguinal hernia 770,000 Femoral hernia 30,000 Umbilical hernia 175,000
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
5/5/2010
1
Hernias: Who, What, When, Where, Why?
J. Scott Roth, MD
Chief, Gastrointestinal Surgery
Director, Minimally Invasive Surgery
University of Kentucky
June 16, 2009
Objectives
Identify patients at risk for herniasUnderstand the etiology and pathophysiology of
herniasReview the demographics of patients with herniasDiscuss common hernia locations and associated
signs and symptomsUnderstand why (or why not) a hernia should be
repairedProvide an overview of techniques for hernia repair
and associated controversies
Common hernia types Inguinal Hernia
Hernia:The protrusion of an organ or other bodily
structure through the wall that normally contains it; a rupture.; p
Inguinal:Of, relating to, or located in the groin.
Randomized Prospective Trial720 men over 5 years – repair vs. observation
Pain limiting activities 5.1% vs. 2.2% NS
23% WW patients cross over to repair23% WW patients cross over to repair17% cross over to WW from repair armComplications similar in initial repair/crossover rep.
2 patients with incarceration events – 1.8/1000 pt-yrsNo strangulation events
Fitzgibbons et al. JAMA 2006
Modern Hernia Repairs
Unchanged from 1890-1980
Primary tissue repair
Many repair types
Fundamentally similar
sutured repair, tension, prolonged recovery, disability, and high recurrence
“It will seem extremely bold to write about the radical repair of inguinal hernias, especially nowadays after all the publications in the past and the restless activity in the present. I thought of a surgical technique of physiological g q p y greconstruction of the inguinal canal, consisting of two openings, an abdominal and a subcutaneous, and of two walls, a posterior and an anterior, with the spermatic cord between them.”
Bassini 1889
Fathers of Inguinal Hernia Repair
Marcy
1871 – original paper on antiseptic hernia repair with closure of internal ring
JAMA 1887 The Cure of Hernia
Bassini
reported 1887, published 1889
Halsted
November 1889
Modified Bassini Repair
5/5/2010
4
Shouldice Hernia Repair
Repair established in 1952 at Shouldice hospital
Commonly referred to as the Bassini-Shouldice repair
Many similarities to Bassini except four layers ofMany similarities to Bassini except four layers of running suture to reconstruct posterior inguinal wall
Local Anesthesia – first to popularize inguinal herniorrhaphy under local anesthesia
1980s – increase in numbers of tension free repairs
1990 b f t i f i1990s – number of tension free repairs surpasses sutured repairs
5/5/2010
5
Trends in Hernia Repair
200000
250000
300000
350000
Bassini
McVay
0
50000
100000
150000
200000
1970 1980 1990 1995 2000 2003
McVay
Shouldice
Lichtenstein
Laparoscopic
Groin Hernia Repairs
Procedure Type Number %
Lichtenstein 295,000 37%
Plug 270,000 34%
Laparoscopy 115,000 14%
Other Mesh 65,000 8%
Tissue rep 55,000 7%
Lichtenstein Hernia Repair
1984 – the tension-free hernioplasty project begun at the Lichtenstein Hernia Institute
Inguinal floor is reinforced by mesh prosthesisMesh placed between transversalis fascia and external oblique
aponeurosis8 x 16 cm polypropylene meshp yp pyRunning suture to inguinal ligamentTwo interrupted sutures superiorly(rectus sheath and internal oblique5cm of mesh lateral to internal ring
A multi-center experience with 6,764 Lichtenstein tension-free hernioplasties
Amid PK, Friis E, Horeyseck, Kux M. Hernia 1999;3(S12):47
Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for Inguinal-Hernia Repair
Liem et al. NEJM 1997
Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for Inguinal-Hernia Repair
Liem et al. NEJM 1997
Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for Inguinal-Hernia Repair
Liem et al. NEJM 1997
Recurrence rate
Open 31 (6%)Open 31 (6%)
Laparoscopic 17 (3%)
p=.05
Cost-Effectiveness of Extraperitoneal Laparoscopic Inguinal Hernia Repair: A Randomized Comparison with
Conventional HerniorrhaphyLiem et. al. Ann Surg 1997
5/5/2010
8
Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair
Memon et al. Br J Surg 2003
Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair
Memon et al. Br J Surg 2003
ConclusionsLaparoscopic Hernia repair
decreased hospital stayquicker return to normal activity/workq yfewer postoperative complicationsLonger operating timestrend toward higher short term recurrences in
laparoscopic (NS)
Study Design
14 Veterans Affairs medical centers
2164 patients randomly assigned
Lichtenstein technique
Laparoscopic repair (TAPP or TEP)
2 year follow up
5/5/2010
9
Open Mesh Versus Laparoscopic Mesh Repair of Inguinal HerniaNeumayer et al. NEJM 2004
Primary Hernia recurrences
Laparoscopic 79/781 (10.1%)
Lichtenstein 30/756 (4.0%)
Recurrent Hernia Rerecurrences
Laparoscopic 8/81 (10.0%)
Lichtenstein 11/78 (14.1%)
Open Mesh Versus Laparoscopic Mesh Repair of Inguinal HerniaNeumayer et al. NEJM 2004
Type 1: GE Junction intermittently migrates Type 1: GE Junction intermittently migrates into mediastinuminto mediastinum
Type 2: GE Junction anchored at Type 2: GE Junction anchored at diaphragm with herniation of adjacent diaphragm with herniation of adjacent p g jp g jstomach into mediastinumstomach into mediastinum
Type 3: Combined Type 1 and 2Type 3: Combined Type 1 and 2Type 4: Viscera other than stomach in Type 4: Viscera other than stomach in
mediastinummediastinum
5/5/2010
13
Hiatal Hernia: Type 1Hiatal Hernia: Type 1
Type 1: GE Junction intermittently migrates into mediastinumType 1: GE Junction intermittently migrates into mediastinum
Hiatal Hernia: Type 2Hiatal Hernia: Type 2
Type 2: GE Junction anchored at diaphragm with herniation of adjacent Type 2: GE Junction anchored at diaphragm with herniation of adjacent stomach into mediastinumstomach into mediastinum
Type IIIType III
Type 3: Combined Type 1 and 2Type 3: Combined Type 1 and 2
Type IVType IV
Type 4: Viscera other than stomach in MediastinumType 4: Viscera other than stomach in Mediastinum
Paraesophageal Hernias: Operation or ObservationParaesophageal Hernias: Operation or ObservationStylopoulos et al Annals of Surgery 236(4): 492Stylopoulos et al Annals of Surgery 236(4): 492--501, 2002501, 2002
Markov ModelMarkov ModelMinimally symptomatic type 2 and 3 HHs (reflux sx only)Minimally symptomatic type 2 and 3 HHs (reflux sx only)Pooled data for elective repair death rate (0Pooled data for elective repair death rate (0--5.2%)5.2%)1997 NIS database mortality for emergency repair (5.4%)1997 NIS database mortality for emergency repair (5.4%)
Literature suggests 17%Literature suggests 17%Literature suggests 17%Literature suggests 17%WW WW –– pooled risk of need for emergent repair 1.16% annuallypooled risk of need for emergent repair 1.16% annuallyAnnual risk of recurrence 1.9%Annual risk of recurrence 1.9%
Elective repair results in reduction of 0.13 Quality of Life Years Elective repair results in reduction of 0.13 Quality of Life Years
Watchful waiting preferred treatment in 83% of patientsWatchful waiting preferred treatment in 83% of patients
Paraesophageal Hernia Repair Mortality in Octogenarians
Poulose et al. J Gastrointest Surg 12:1888-1892, 2008
2005 National Inpatient Survey Database
Paraesophageal Hernias
excluded congenital or traumatic
1005 patients1005 patients
30 day outcomes
Recurrences/readmissions not evaluated
Includes Open and Laparoscopic Operations
Paraesophageal Hernia Repair Mortality in Octogenarians
Poulose et al. J Gastrointest Surg 12:1888-1892, 2008
5/5/2010
15
Conclusions
Hernias are common and frequently encountered
Most abdominal hernias should be repaired electively to avoid devastating complications
Watchful waiting is appropriate in high riskWatchful waiting is appropriate in high risk ASYMPTOMATIC patients
All symptomatic hernias should be repaired
Minimally Invasive Surgery offers improved outcomes and quicker return to activities for all hernia repairs