WHY LAP INGUINAL HERNIA REPAIR IS PROGRESSING AT SLOW MOMENTUM ? OUR EXPERIENCE

WHY LAP INGUINAL HERNIA REPAIR IS PROGRESSING AT SLOW MOMENTUM ? OUR EXPERIENCE

Authors:

DR. AYMEN KHAN

DR. HRIDAY HALOI

DR. D K CHOUDHURY

DR. H K BHATTACHARYA

Department of Surgery

Gauhati Medical College

After introduction of lap cholecystectomy laparoscopy continues to explore in different advanced surgical field .

Lap inguinal hernia repair is considered to be a widely accepted procedure all over the world at present

But it seems that the procedure is not getting the fast momentum like laparoscopic cholecystectomy in common in our society.

AIMS AND OBJECTIVES To evaluate possible factors for which the

procedure is less commonly done by even highly skilled lap surgeon in spite of large volume of inguinal hernia cases in our society

To obtain views of the patients presenting with inguinal hernia towards laparoscopic repair

To share our experience while doing both lap inguinal hernia repair and open repair

MATERIALS AND METHODS

We studied 60 cases of inguinal hernia attending our OPD in last six months

Complicated hernia excluded from study

Hernia in pediatric age group also excluded

Hernia with morbid condition like cardiac cause and above 70 years excluded from the study

All 60 cases of the study were asked the following question

Do you know that there are two methods of operation for inguinal hernia, which are open operation and laparoscopic repair ??

56 (93.3%) cases of total 60 cases of inguinal hernia of our series were un aware of the lap hernia procedure

4(6.7%) Patients were aware of the lap hernia procedure

Only 4(6.7%) cases out of 60 cases attended our OPD for lap hernia repair

Rest 56 cases out of 60 cases attend to get operated to get rid of their hernia problem

Following informations were given to the patients

You can be operated either by laparoscopy or by open technique

In laparoscopy few holes will be made and in open , incision will be made

You will need to undergo general anaesthesia in laparoscopy

Spinal anesthesia will be sufficient for most of the cases in open repair

Both the cases you need to be hospitalized for one day

56 cases raised the following question Which procedure is better according

to the surgeon Accordingly the patients will decide the

type of procedure to undergo

Patients were informed the following No favouritism was given to any procedure Both the technique has their own pro and

cones Laparoscopy is cosmetically better Post operative pain is said to be less than open Regarding recurrence both the technique

carries almost same recurrence Cost will be high if tacker wants to be used But we can cut down cost by suturing and

avoiding tacker

38(63.3%) cases of 56 cases refused to undergo laparoscopic hernia repair after getting proper information from us as NICE guideline

16(26.6%) cases refused to undergo the procedure initially because of high cost but agreed to undergo lap by suturing technique

Two patients who were unaware of the procedure were convinced to undergo lap repair with tacker

Intra Operative Observation

All the patients opted for laparoscopy were done by TAPP procedure

Right sided inguinal hernia repair comparatively have easier ergonomics than left side for us during the surgery

Duration of surgery was more in initial learning curve up to 2 and half hours to three hours where tacker was avoided and repair was done by suturing

Later duration was reduced to 1 and half hours to 2 hours We found direct hernia is easier to dissect than indirect

hernia Careful dissection required specially during paritalisation

to prevent vascular injury

Post Operative Observation

Post operative pain was 50% less in lap procedure than open

Both group were kept hospitalized for one day

Oral feeding started after 24 hours in both groups

Both the groups were mobilised next day

COMPLICATIONS LAP HERNIA REPAIR

OPEN REPAIR

WOUND INFECTION I 2

SEROMA 1 NIL

HYDROCELE NIL NIL

INDURATION OF CHORD AND TETIS

NIL 7

ATYPICAL MYCOBACTERIA

INFECTION

1 0

MESHNEURALGIA NIL 3

PARASTHESIA OF GROIN NIL 1

LAP HERNIA OPEN HERNIASKILL OF LAPAROSCOPY NEEDS HIGH AND TO BE

LEARNED BY SURGEON BY HIMSELF BY

PRACTISCE WITH PATIENCE

NORMAL

COST HIGH NORMAL

LIFE THREATINING COMPLICATIONS

CHANCES ARE HIGH IF CARELESS

VERY RARE

COST REDUCTION ATTEMPT

SUTURING IS NOT ENJOYED BECAUSE OF POOR ERGONOMICS OF

SUTURING

NOT REQUIRED

MOTIVATION OF PATIENTS

DEPENDS UPON SURGEONS’

CONFIDENCE

NOT REQUIRED

SUMMARY

Post operative pain was less in lap hernia repair group than in the open group

Better cosmesis in lap hernia group than open group

No significance difference of complications observed in either group

Cost is high in lap hernia because of use of large size mesh and tacker

If suturing is done in stead of tacker to curtail cost it requires extra time and strain to the surgeon

In terms of recurrence the rate is same in both open and lap cases .

There is no difference in recurrence in both technique in reported large studies also

Open repair can be done either in spinal or local anesthesia

CONCLUSION Cost of the procedure is much higher than the open

technique which is not usually accepted by average patients volume in first look

Lap hernia repair cannot claim ,at present moment, any boosting results in terms of recurrences, complication, return to work in comparison to open repair except in terms of cosmesis and post operative pain .

Lap hernia repair requires complex and careful dissection in vital area as opposed to very simple open lichtenstein repair so learning curve of the surgeon is high to acquire skill

Motivation of patients for lap hernia will mostly depend on surgeon and his credibility to deliver the similar result like open hernia without compromising the overall safety of the patients.

THANK YOU

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