Objectives Common hernia types Inguinal Hernia Hesselbach`s

11/30/2009
Objectives
Hernias: Who, What, When, Where,
Why?
J. Scott Roth, MD
Chief, Gastrointestinal Surgery
Director, Minimally Invasive Surgery
University of Kentucky
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
June 16, 2009
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.
Myopectineal Orifice of Fruchaud
Hesselbach’s Triangle
MPO
Superior- arched fibers of int.
oblique
Inferior – iliac bone
Medial – rectus abdominis m.
Lateral – iliopsoas &
iliopectineal arch
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Inguinal Hernia
U.S. Abdominal Hernia Repairs
2003
Inguinal hernia
Femoral hernia
Umbilical hernia
Epigastric, spigelian, etc.
Incisional hernia
770,000
30,000
175,000
80,000
105,000
Hernia Repairs
Sex(%)
Procedure
Inguinal Hernia
Femoral Hernia
Umbilical Hernia
Incisional Hernia
Others –spig/epig
M
90
30
57
35
43
F
10
70
33
65
57
Age(%)
<15
18
<1
13
<1
1
15-44 45-64 >65
29
23
30
19
29
48
33
36
17
25
35
39
32
40
26
Based on projected growth from 1996 National Survey of Ambulatory
Surgery and National Center for Health Statistics
Hernia Management
Medical Management
Non-operative
Trus/Hernia belt
Operative
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External Support
Watchful Waiting
Randomized Prospective Trial
720 men over 5 years – repair vs. observation
Pain limiting activities 5.1% vs. 2.2% NS
23% WW patients cross over to repair
17% cross over to WW from repair arm
Complications similar in initial repair/crossover rep.
2 patients with incarceration events – 1.8/1000 pt-yrs
No 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
g
technique
q of p
physiological
y
g
reconstruction 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
Modified Bassini 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
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Shouldice Hernia Repair
Shouldice Repair
Repair established in 1952 at Shouldice hospital
Commonly referred to as the Bassini-Shouldice
repair
Many similarities to Bassini except four layers of
running suture to reconstruct posterior inguinal
wall
Local Anesthesia – first to popularize inguinal
herniorrhaphy under local anesthesia
Shouldice Complications
CB McVay
The Pathologic Anatomy of the More Common
Hernias and their Anatomic Repair 1954
Testicular atrophy – 0.36%
Hematomas – 0.3%
Infections – 1%
Hydroceles
y
– 0.7%
Dysejaculation – 0.25%
Mortality – 0.009%
Recurrence rate - 0.5% primary; 1.5%recurrent
250,000 repairs over 20 years
McVay Hernia Repair
Tension Free Hernia Repairs
The past twenty years
1980s – increase in numbers of tension free
repairs
1990 – number
1990s
b off ttension
i ffree repairs
i
surpasses sutured repairs
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Trends in Hernia Repair
350000
300000
250000
Bassini
McVay
Shouldice
Lichtenstein
Laparoscopic
200000
150000
100000
50000
Groin Hernia Repairs
Procedure Type
Lichtenstein
Plug
Laparoscopy
Other Mesh
Tissue rep
Number
295,000
270,000
115,000
65,000
55,000
%
37%
34%
14%
8%
7%
0
1970
1980
1990
1995
2000
2003
Lichtenstein Hernia Repair
1984 – the tension-free hernioplasty project begun at the Lichtenstein
Hernia Institute
Inguinal floor is reinforced by mesh prosthesis
Mesh placed between transversalis fascia and external oblique
aponeurosis
polypropylene
yp py
mesh
8 x 16 cm p
Running suture to inguinal ligament
Two interrupted sutures superiorly(rectus sheath and internal oblique
5cm of mesh lateral to internal ring
Stoppa Repair
Giant Prosthetic Reinforcement of the Visceral Sac
(GPRVS)
A multi-center experience with 6,764 Lichtenstein
tension-free hernioplasties
Amid PK, Friis E, Horeyseck, Kux M. Hernia 1999;3(S12):47
6,764 Inguinal Hernia repairs
4 surgeons at 4 institutions
Recurrence rate 0.1 to 0.9 percent
Complications – infection, seroma,
hematoma, neuralgia ~ 1%
Stoppa Repair
Polyester mesh to correct the structural
weakness of the groin
p through
g self-stabilization
Sutureless repair
Technique
midline or pfannensteil incision
preperitoneal approach
Stoppa et. al. Surg Clin N Am 1984
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Stoppa Repair
Giant Prosthetic Reinforcement of the Visceral Sac
(GPRVS)
Total patients 1992
Septic complications 2.1%
Follow up rate 79.2%
Follow up duration 2-12 years
Recurrence rate: overall 1.1%
primary hernia 0.56%
recurrent hernia 1.3%
Laparoscopic Inguinal
Herniorrhaphy
First described in 1990
Techniques
Plug
Closure of internal ring
IPOM – intraperitoneal only of mesh
TAPP – transabdominal properitoneal
TEP – totally extraperitoneal
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Comparison of Conventional Anterior Surgery and
Laparoscopic Surgery for Inguinal-Hernia Repair
Liem et al. NEJM 1997
Randomized Multicenter Trial – 87 surgeons
primary
p
y and initially
y recurrent unilateral inguinal
g
hernias
487 Extraperitoneal laparoscopic repairs
507 Anterior repairs – Bassini(29%), Shouldice(22%),
Bassini-McVay(19%), McVay(9%),others
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
Cost-Effectiveness of Extraperitoneal Laparoscopic
Inguinal Hernia Repair: A Randomized Comparison with
Conventional Herniorrhaphy
Liem et. al. Ann Surg 1997
Recurrence rate
Open
31 (6%)
Laparoscopic 17 (3%)
p=.05
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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
Conclusions
Laparoscopic Hernia repair
decreased hospital stay
quicker return to normal activity/work
q
y
fewer postoperative complications
Longer operating times
trend 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
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Open Mesh Versus Laparoscopic Mesh Repair of Inguinal Hernia
Neumayer et al. NEJM 2004
Primary Hernia recurrences
Laparoscopic 79/781 (10.1%)
Lichtenstein 30/756 (4.0%)
Open Mesh Versus Laparoscopic Mesh Repair of Inguinal Hernia
Neumayer et al. NEJM 2004
Highly experienced Surgeons (>250 cases)
Primary Hernia Recurrences
Lap 13/253 (5.1%)
Open 26/635 (4.1%)
Recurrent Hernia recurrence
Lap 1/28 (3.6%)
Open 11/64 (17.2%)
Inexperienced Surgeons
Recurrent Hernia Rerecurrences
Laparoscopic 8/81 (10.0%)
Lichtenstein 11/78 (14.1%)
Primary Hernia Recurrences
Lap
65/528 (12.3%)
Open
3/121
(2.5%)
97/989 (10%)
Recurrent Hernia Recurrence
no statistical power
Lap patients converted to open – various reasons
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Incisional Hernias
…“a hernia repair is equivalent to
repairing drywall”……
The Baltimore Sun
August 13, 2006
Common clinical problem
More than 10% of laparotomy incisions
1.3 million laparotomies per year
150,000 hernias created annually
6-15% incidence of incarceration
2% incidence of strangulation
Biology of Hernias
Incisional Hernia Repairs in
Non-Federal US Hospitals
Mechanisms of Recurrence
Carlson et al. Hernia 2008
infection, lateral detachment of mesh, inadequate mesh fixation, inadequate mesh,
inadequate mesh overlap
Inlay with 2.5 fold increased recurrence compared to underlay, sandwich, overlay
Awad et al. JACS 201(1):132-140, 2005
Smokers with a 4 Fold increase in Incisional Hernia
formation
Sorenseon et al. Arch Surg 140:119-123, 2005
Decreased Collagen I/III ratio associated with hernia
formation
Junge et al. Langenbecks Arch Surg 389:17-22, 2004
Progression to Hernia Recurrence
Washington State Database 1987-1999
10,822 patients
23%
13 years
12%
5 years
Flum et al. Ann Surg 137(1):129-135, 2003
Flum et al. Ann Surg 137(1):129-135, 2003
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Rates of Reoperation
Primary vs. Mesh Repair
Luijendijk RW, et al; NEJM, 2000
Progression to Reoperation
by use of mesh
Open Incisional Hernia Repair
•
•
•
•
•
Pascal’s Principle
Overlay
Inlay
Underlay
Sandwich
Rives-Stoppa technique
Physiology of Hernias
Blaise Pascal (1623-1662)
liquid in a closed container at rest
ttransmits
it a pressure change
h
without
ith t lloss
to the walls
pressure in a gas or fluid is the same in
all directions
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Law of LaPlace
Physiology of Hernias
Wall tension(T) is proportional to pressure(P)
and radius(R)
Increased Radius Æ Increased tension
T inversely
i
l proportional
ti
l tto wallll thi
thickness(M)
k
(M)
T= P x R / 2M
r
T= tension
P= pressure
R= radius
M= wall thickness
Complications and Recurrence are
Decreased with Laparoscopic
Approach
40
35
30
25
Lap
Open
20
15
10
5
0
Complications
Hiatal Hernias
2-5% of population
Pathophysiology poorly understood
95% of HHs are Sliding Type I hernias
69% asymptomatic
27% small HH with reflux
35% large(>2cm) with reflux
Paraesophageal hernias 22-5%(types 2,3,4)
Recurrence
Hiatal Hernias: defined
Type 1: GE Junction intermittently migrates
into mediastinum
Type 2: GE Junction anchored at
diaphragm
p g with herniation of adjacent
j
stomach into mediastinum
Type 3: Combined Type 1 and 2
Type 4: Viscera other than stomach in
mediastinum
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Hiatal Hernia: Type 1
Hiatal Hernia: Type 2
Type 1: GE Junction intermittently migrates into mediastinum
Type 2: GE Junction anchored at diaphragm with herniation of adjacent
stomach into mediastinum
Type III
Type 3: Combined Type 1 and 2
Type IV
Type 4: Viscera other than stomach in Mediastinum
Paraesophageal Hernia
Types 2,3 & 4
30% present with severe complications if untreated
Hill, Tobias, Arch Surg 96:73596:735-744, 1968
Tremendous controversy
Evaluation
When to operate – if at all
Which operation
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Presentation
Volvulus
Often asymptomatic
Suspicion based on
imaging
Asymptomatic Paraesophageal Hernia
Repair
Paraesophageal Hernia Repair
Mortality in Octogenarians
Poulose et al. J Gastrointest Surg 12:1888-1892, 2008
Paraesophageal Hernias: Operation or Observation
Stylopoulos et al Annals of Surgery 236(4): 492492-501, 2002
Markov Model
Minimally symptomatic type 2 and 3 HHs (reflux sx only)
Pooled data for elective repair death rate (0(0-5.2%)
1997 NIS database mortality for emergency repair (5.4%)
Literature suggests 17%
WW – pooled risk of need for emergent repair 1.16% annually
Annual risk of recurrence 1.9%
Elective repair results in reduction of 0.13 Quality of Life Years
Watchful waiting preferred treatment in 83% of patients
2005 National Inpatient Survey Database
Paraesophageal Hernias
excluded congenital or traumatic
1005 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
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Conclusions
Hernias are common and frequently encountered
Most abdominal hernias should be repaired
electively to avoid devastating complications
Watchful 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
THANK YOU
J. Scott Roth, MD
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