Objectives. Hesselbach s Triangle 11/30/2009. Myopectineal Orifice of Fruchaud. Hernias: Who, What, When, Where, Why?

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1 Objectives Hernias: Who, What, When, Where, Why? J. Scott Roth, MD Chief, Gastrointestinal Surgery Director, Minimally Invasive Surgery University of Kentucky June 16, 2009 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 Hesselbach s Triangle MPO Superior- arched fibers of int. oblique Inferior iliac bone Medial rectus abdominis m. Lateral iliopsoas & iliopectineal arch 1

2 Inguinal Hernia U.S. Abdominal Hernia Repairs 2003 Hernia Repairs Inguinal hernia 770,000 Femoral hernia 30,000 Umbilical hernia 175,000 Epigastric, spigelian, etc. 80,000 Incisional hernia 105,000 Based on projected growth from 1996 National Survey of Ambulatory Surgery and National Center for Health Statistics Sex(%) Age(%) Procedure M F < >65 Inguinal Hernia Femoral Hernia < Umbilical Hernia Incisional Hernia < Others spig/epig Hernia Management Medical Management Non-operative Trus/Hernia belt Operative 2

3 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 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 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

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 of running suture to reconstruct posterior inguinal wall Local Anesthesia first to popularize inguinal herniorrhaphy under local anesthesia Shouldice Repair Shouldice Complications Testicular atrophy 0.36% Hematomas 0.3% Infections 1% Hydroceles 0.7% Dysejaculation 0.25% Mortality 0.009% Recurrence rate - 0.5% primary; 1.5%recurrent CB McVay The Pathologic Anatomy of the More Common Hernias and their Anatomic Repair ,000 repairs over 20 years McVay Hernia Repair Tension Free Hernia Repairs The past twenty years 1980s increase in numbers of tension free repairs 1990s number of tension free repairs surpasses sutured repairs 4

5 Trends in Hernia Repair Bassini 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 prosthesis Mesh placed between transversalis fascia and external oblique aponeurosis 8 x 16 cm polypropylene py mesh Running suture to inguinal ligament Two interrupted sutures superiorly(rectus sheath and internal oblique 5cm 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 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 Giant Prosthetic Reinforcement of the Visceral Sac (GPRVS) Stoppa Repair Polyester mesh to correct the structural weakness of the groin Sutureless repair through self-stabilization Technique midline or pfannensteil incision preperitoneal approach Stoppa et. al. Surg Clin N Am

6 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 6

7 Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for Inguinal-Hernia Repair Liem et al. NEJM 1997 Randomized Multicenter Trial 87 surgeons primary and initially recurrent unilateral inguinal 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 7

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 Conclusions Laparoscopic Hernia repair decreased hospital stay quicker return to normal activity/work 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 8

9 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%) Recurrent Hernia Rerecurrences Laparoscopic 8/81 (10.0%) Lichtenstein 11/78 (14.1%) Open Mesh Versus Laparoscopic Mesh Repair of Inguinal Hernia Neumayer et al. NEJM 2004 Highly experienced Surgeons (>250 cases) Primary Hernia Recurrences Recurrent Hernia recurrence Lap 13/253 (5.1%) Lap 1/28 (3.6%) Open 26/635 (4.1%) Open 11/64 (17.2%) Inexperienced Surgeons Primary Hernia Recurrences Recurrent Hernia Recurrence Lap 65/528 (12.3%) no statistical power Open 3/121 (2.5%) 97/989 (10%) Lap patients converted to open various reasons 9

10 a hernia repair is equivalent to repairing drywall The Baltimore Sun August 13, 2006 Incisional Hernias 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 Mechanisms of Recurrence infection, lateral detachment of mesh, inadequate mesh fixation, inadequate mesh, inadequate mesh overlap Incisional Hernia Repairs in Non-Federal US Hospitals Carlson et al. Hernia 2008 Inlay with 2.5 fold increased recurrence compared to underlay, sandwich, overlay Awad et al. JACS 201(1): , 2005 Smokers with a 4 Fold increase in Incisional Hernia formation Sorenseon et al. Arch Surg 140: , 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 ,822 patients 23% 13 years 12% 5 years Flum et al. Ann Surg 137(1): , 2003 Flum et al. Ann Surg 137(1): ,

11 Rates of Reoperation Primary vs. Mesh Repair Luijendijk RW, et al; NEJM, 2000 Progression to Reoperation by use of mesh Open Incisional Hernia Repair Overlay Inlay Underlay Sandwich Rives-Stoppa technique Pascal s Principle Physiology of Hernias Blaise Pascal ( ) liquid in a closed container at rest transmits a pressure change without t loss to the walls pressure in a gas or fluid is the same in all directions 11

12 Law of LaPlace Physiology of Hernias Wall tension(t) is proportional to pressure(p) and radius(r) Increased Radius Increased tension T inversely proportional to wall thickness(m) T= P x R / 2M T= tension P= pressure R= radius M= wall thickness r Complications and Recurrence are Decreased with Laparoscopic Approach Complications Recurrence Lap Open 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 2-5%(types 2,3,4) Hiatal Hernias: defined Type 1: GE Junction intermittently migrates into mediastinum Type 2: GE Junction anchored at diaphragm with herniation of adjacent stomach into mediastinum Type 3: Combined Type 1 and 2 Type 4: Viscera other than stomach in mediastinum 12

13 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 IV Type 3: Combined Type 1 and 2 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: , 744, 1968 Tremendous controversy Evaluation When to operate if at all Which operation 13

14 Presentation Volvulus Often asymptomatic Suspicion based on imaging Asymptomatic Paraesophageal Hernia Repair Paraesophageal Hernias: Operation or Observation Stylopoulos et al Annals of Surgery 236(4): , 2002 Markov Model Minimally symptomatic type 2 and 3 HHs (reflux sx only) Pooled data for elective repair death rate (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 Paraesophageal Hernia Repair Mortality in Octogenarians Poulose et al. J Gastrointest Surg 12: , 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: ,

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 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 15