Factors affecting recurrent hernia. An analysis of more than 4300 hernia operations. Clinica Guarnieri - Rome - Italy

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1 Factors affecting recurrent hernia. An analysis of more than 4300 hernia operations Francesco Guarnieri Moscatelli Franco Smaldone Walter Cellamare Cosimo Clinica Guarnieri - Rome - Italy

2 Hernias Primary Inguinal hernias Year Hernias Recurrent External Oblique Direct Mixed Femoral Abdominal Average age 58 (1-99 years) Primary hernias: M/F = 0,9 Recurrent hernias: M/F = 0,4 Anesthesia Primary hernias: 73 % local, 15 % general, 12 % spinal Recurrent hernias: 60 % local, 25 % general, 15 % spinal Postoperative Complications Primary hernias: Seromas 6%, Hematoma 0,5 %, Transient Testicular Edema 0,4 %, Infections 0,3 %, Testicular Atrophy 0,2 %, Recurrences 0,7 % Recurrent hernias: Sieromas 15%, Hematoma 2,4 %, Infections 0,5 %, Testicular Atrophy 1 %, Recurrences 0,7 % Follow-Up (1 to 10 years) = 2346/2870 = 81 %

3 Recurrences DIAGNOSI Categoria Sottocategoria TECNICA RETE 1 mese 6 mesi 1 Anno 18 mesi 2 anni 4 anni >= 5 anni E Inguinale Indiretta N N N N N N N R R E Inguinale Indiretta N N N N N N N N R E Inguinale Indiretta N N N N N N N N R D Inguinale Diretta N N N N N N N O O E Inguinale Indiretta V N N T T T R R R D Inguinale Diretta N N N N N N N N R E Inguinale Indiretta N N N N N R O O O E Inguinale Indiretta N N N N N N N N R D Inguinale Diretta T N N N N N N R R D Inguinale Diretta T N N N N N N N R + Inguinale Mista T N N N N R R R R E Inguinale Indiretta P N N R R R R R R E Inguinale Indiretta N N N N R R R R R E Inguinale Indiretta N N N N R R R R R E Inguinale Indiretta P N N R R R R R R + Inguinale Mista P N N R R O O O O E Inguinale Indiretta P N N R R R R R R - Inguinale Mista T N N N N N R R R D Inguinale Diretta T N N N R R R R R E Inguinale Indiretta N N N N R R R R R D Inguinale Diretta T N N N R R R R R D Inguinale Diretta T N N N R R R R R E Inguinale Indiretta P N N R R R R R R + Inguinale Mista P N N R R R R R R E Inguinale Indiretta N N N N R R R R R Recurrences after primary hernia operation Recurrences Mesh No Mesh Primary Operation Recurrence Rate 0 0,8 Overall Recurrence 0,7 25 recurrences for primary hernia without mesh (14 Indirect, 7 direct, 4 mixed) 50 % after one year 75 % after 4 years Re-Recurrences DIAGNOSI Categoria Sottocategoria TECNICA RETE 1 mese 6 mesi 1 Anno 18 mesi 2 anni 4 anni R Recidiva 1 Recidiva V S N R O O O O R Recidiva 1 Recidiva F S N N N R R R R Recidiva 1 Recidiva C S N N R R R R R Recidiva 1 Recidiva V S R O O O O O R Recidiva 1 Recidiva L S R R R R R R 4 Recidiva 4 Recidiva C S N N N R R R 2 Recidiva 2 Recidiva F S N R R R R R R Recidiva 1 Recidiva F S N N R R R R R Recidiva 1 Recidiva F S N N N R R R Recurrences after recurrent hernia operation Recurrences Mesh 9 9 Primary Operation 331 Recurrence Rate 2,7 9 recurrences for recurrent hernia all with mesh 66% after one year 100 % after four years

4 Technique Used: Every surgeon should use his own technique based on his experience... Antonio Guarnieri We are using the Antonio Guarnieri s technique. This technique can be used with or without mesh. We have 0.7 % recurrence rate (more than 3500 hernia operations for primary inguinal hernia). No recurrence was observed in patients treated with mesh (for primary hernia). This technique was developed on December From December 1988 to December 2003 we have performed more than 4300 hernia operation. The aim of this technique is to modify the anatomy preserving the physiology of the inguinal canal. It was first published on the American Journal of Surgery (164: 70-73, 1992). It is now well described on chapter eleven, Nyhus and Condon s Hernia book fifth edition. Antonio Guarnieri died on May 5th, 2003.

5 Factors affecting recurrent hernia An analysis of more than 4300 hernia operations with the Guarnieri s technique Surgical Experience Technique Used Patient S E T U P

6 The surgeon must: Research Reinforce passive areas (with mesh if necessary) Search concurrent subclinical primary hernias Avoid suture tension Reduce the surface of passive areas (the inguinal triangle) Calibrate the internal ring Have a good patient To Avoid Recurrence

7 The Technique: SPARE Surgeon must calibrate the internal ring easily Permit a good reinforcement of the abdominal wall Avoid recurrences Respect of the physiology Easy to be reproduced and performed

8 The Patient: MIMIC Multiple primary hernias could enhance the recurrence rate Internal Ring is a critical point Male develop recurrence more than female (2x) Inguinal triangle is a critical point Collagen defects and other favoring factors

9 Surgeon s behavior: the use of mesh Year Hernias Mesh % Mesh OPERATORS A F FM A F FM A F FM A F FM A F FM A F FM A F FM W A F FM W A F FM W A F FM W A F FM W A F FM W A F FM W A F FM W A F FM W F FM W C A B C D E Mixed hernias more often require mesh Expert surgeons use the mesh less The mesh was always used in case of femoral and recurrent hernias Inguinal and femoral hernias Type Mesh % 339 E D M R C* Type Mesh % 1704 E D M

10 Lesson learned from 1990: We operated a femoral pseudo-recurrence The exploration of the femoral canal can reduce 2,2 % recurrences Femoral Hernias Simple 58 From 1988 Mixed 34 From 1990 Total 92 Femoral Hernias Simple 17 Mixed Subclinical Mixed 15 Primary Inguinal 666 % Subclinical 2,2

11 Recurrences ANNO Recidive Operate Alte Basse Miste Recidive Operate M F Most recurrences are high calibration of the internal ring the upper portion of the inguinal triangle the sail effect is higher the suture tension is higher

12 The sail effect and the Laplace law Laplace's law applies to elastic cylindrical or spherical containers, which undergo an internal pressure greater than the external one: the relationship between the transmural pressure (P), the tension of the wall in a point (T) and the bend radius (r) of the wall in that point is T= P x r in a cylindrical container, T= P x r/2 in a spherical container. The surgeon must avoid suture tension but have to reduce and reinforce the passive areas to minimize the so called SAIL EFFECT

13 What we have learned Multiple primary hernias predispose to recurrence because surgeons use the mesh more frequently The systematic exploration of the femoral canal can reduce the risk of recurrence of 2.2 % No recurrence in patients operated with the mesh An expert surgeon can reach less than 1 % recurrence rate without using the mesh (with patient selection) The internal ring and the base of the inguinal triangle are critical points in hernia operation because most of recurrences are found in the high portion of the inguinal canal