Residency Teaching Conference March 19, 2010

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2 Residency Teaching Conference March 19, 2010

3 Add Biologic basis of disease (mmp, etc) Anatomy Inguinal hernias Open vs Laparoscopic Incisional Ventral Open vs Laparoscopic

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13 Iliohypogastric nerve Origin T12 L1 L2 Sensory nerve to suprapubic area Some motor innervation to lower abdominal muscles Second most commonly entrapped nerve Ilioinguinal nerve Origin T12 L1 L2 Sensory nerve to base of penis or mons pubis, scrotum or labia majora, medial aspect of the thigh Most commonly entrapped Genitofemoral nerve (Genital branch) Origin L 1 2 Sensory nerve to anterior scrotum/labia & medial thigh Motor nerve to cremaster muscle (Cremaster reflex)

14 Nine months after right inguinal hernia repair, a 65 year old man presents with chronic right groin pain. The operative report describes routine tension free herniorrhaphy with mesh (with the mesh in the anterior position). PE and CT scan do not reveal a recurrent hernia. He has reproducible pain with percussion just medial to his right ASIS. The most appropriate step now would be A. MRI of the lumbar spine B. Groin exploration C. Mesh excision and native tissue hernia repair D. Ilioinguinal and iliohypogastric nerve blocks E. neurontin

15 Nine months after right inguinal hernia repair, a 65 year old man presents with chronic right groin pain. The operative report describes routine tension free herniorrhaphy with mesh (with the mesh in the anterior position). PE and CT scan do not reveal a recurrent hernia. He has reproducible pain with percussion just medial to his right ASIS. The most appropriate step now would be A. MRI of the lumbar spine B. Groin exploration C. Mesh excision and native tissue hernia repair D. Ilioinguinal and iliohypogastric nerve blocks E. neurontin

16 There is no doubt that the first appearance of the mammal, with his unexplainable need to push his testicles out of their proper home into the air, made a mess of the three layered abdominal wall that had done the reptiles well for 200 million years. Sir W. H. Ogilvie, 1960

17 OPEN Prosthetic Plug and Patch Lichtenstein Nonprosthetic Bassini Shouldice McVay Cooper s ligament LAPAROSCOPIC TAPP TEP IOM

18 RCTs comparing lap vs open inguinal hernia repair suggest all of the following EXCEPT A. increased incidence of intraoperative complications B. Similar incidence of life threatening complications C. Similar rate of long term complications D. Improved pain in short term follow up E. Increased recurrence rates at 2 years for surgeons with <250 cases

19 RCTs comparing lap vs open inguinal hernia repair suggest all of the following EXCEPT A. increased incidence of intraoperative complications B. Similar incidence of life threatening complications C. Similar rate of long term complications D. Improved pain in short term follow up E. Increased recurrence rates at 2 years for surgeons with <250 cases

20 Inguinal Ventral Suture Mesh Suture Mesh Recurrence 15% 5% 50% 20% Infection 3% 3% 5% 18%

21 Unilateral inguinal hernia Bilateral inguinal hernia Inguinal and umbilical hernia Recurrent inguinal hernia

22 Absolute Inability to tolerate general anesthesia Evidence of incarceration with ischemia or perforation Relative Multiple lower midline surgeries Prostatectomy Pelvic radiation therapy Prior laparoscopic hernia repair Large scrotal hernia

23 ADVANTAGES Less pain Shorter recovery Earlier return to work Fewer nerve injuries? Decreased recurrence? Contralateral dx/rx Improved cosmesis Ideal for bilateral and/or recurrent hernias DISADVANTAGES Transgression of peritoneal cavity General anesthesia More difficult Increased cost Longer operative time? Equipment

24 Skin incision ASIS pubic tubercle Through subcutaneous tissue to external oblique aponeurosis Opened through to external ring Dissect underneath the external aponeurosis Identify nerves Mobilize cord structures Isolate the hernia sac Repair of the Inguinal Floor Skin Closure

25 Prosthetic Plug and Patch Lichtenstein Nonprosthetic Bassini Shouldice McVay Cooper s ligament

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28 TAPP Trans Abdominal Pre Peritoneal TEP Totally Extra Peritoneal

29 Abdominal access Inguinal hernia assessment Peritoneal incision Creation of preperitoneal space Hernia reduction Cord dissection Mesh placement/fixation Peritoneal closure

30 Midline periumbilical 10 or 5 mm port Two lateral 5mm ports or midline and contralateral lateral port 30 degree 5/10 mm scope

31 Evaluate for incarcerated structures Landmarks: Midline (bladder) median umbilical ligament Medial umbilical ligaments obliterated umbilical arteries Lateral umbilical ligaments epigastric vessels Hernia defect

32 Gonadal Vessels Vas Deferens Right Groin, Male

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36 Start lateral Avoid epigastric vessels Watch for sliding hernia contents Stay above peritoneal defects

37 Start lateral identify the edge of indirect sac Identify cooper s ligament Just medial to epigastric vessels Avoid accessory obturator vessels Maintain epigastric vessels on abdominal wall

38 Remove all preperitoneal fat to help identify edges of defect Intermittent external palpation Avoid cautery

39 Reduce all lipomatous tissue Use external compression and intraperitoneal view to help differentiate indirect sac from cord Skeletonize cord even with direct hernias Remove peritoneal attachments from cord all the way to point where vas bends medially Circumferential dissection for indirect hernias

40 Broad coverage: 2 3 cms minimum Tack to Cooper s Ligament Tack medially and high laterally Stay above the iliopubic tract Slit mesh/two piece coverage for indirect hernias (debatable) Avoid epigastric vessels, bladder, iliac vessels Ensure that the peritoneum is covered completely

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42 Complete mesh coverage Avoid epigastric vessels, bladder, iliac vessels Avoid peritoneal gaps Use other structures as needed Medial umbilical folds Reduced peritoneal sacs dual mesh products

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45 Advantages over TEP Easier to identify initial hernia defect and presence of sac after dissection Possibly decreases recurrence rate Less chance for injury to bladder, epigastric vessels, incarcerated/sliding structures Easier to learn/easier to teach Can be used in more diverse group of patients Disadvantages vs.tep Requires intraperitoneal access Shoulder pain Requires peritoneal flap closure Longer operative time

46 Use of balloon dissector to develop preperitoneal space into the operating field 1 st view is of the dissected space Can have poor visualization from bloody field Orientation can be more difficult than in TAPP

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50 DIRECT Medial to the epigastric vessels The balloon reduces many of these Must always examine the cord to ensure that the peritoneum is swept back to the umbilicus. INDIRECT If there is a large indirect hernia sac: transect the sac as far distally as possible Use an endoloop for proximal sac

51 DO Place the first tack on the highest medial aspect Place the next tack along Cooper s ligament Place tacks laterally only where you can feel the tacker above the iliopubic tract DO NOT Tack or staple lower than Cooper s ligament Tack or staple on or near the cord structures Tack or staple into or below the iliopubic tract Tack or staple into the epigastric vessels

52 Indirect sac can not lie below the mesh Mesh needs to lie flat on the Psoas muscle Mesh needs to not only cover Hesselbach s triangle but from midline to Iliac crest and cover cord structures by several cms Large direct hernias need to be covered by 2cm medially and superiorly Can always use more mesh

53 The patient must be able to tolerate general anesthesia Good for patients with bilateral, recurrent, or motivated patients TEP not good for prior plug&patch recurrences (do TAPP), other prior RP surgeries, or future kidney transplant patients Tackers work well To prevent pneumoperitoneum in TEP: Don t overinflate the balloon Keep the insufflation 12 If you make a hole: fix it, deflate the pneumoperitoneum with a veress needle.

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55 Sepsis Age UTI COPD Steroids General Debility

56 Characteristics of patients who develop recurrences after lap ventral hernia repair include all of the following EXCEPT A. Larger hernia size B. Longer operative time C. Male sex D. Previous hernia repair E. BMI>40

57 Characteristics of patients who develop recurrences after lap ventral hernia repair include all of the following EXCEPT A. Larger hernia size B. Longer operative time C. Male sex D. Previous hernia repair E. BMI>40

58 Laparoscopic Open Vest over pants Overlay Inlay Underlay Sandwich (double layer) Wrap around (pita) Rives Stoppa Component Separation

59 Placement of ports Insufflation Reduce hernia contents Place mesh in the intra abdominal cavity, adjacent to viscera

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69 Tissue to tissue Onlay Inlay Retrorectus (Rives Stoppa) Underlay

70 Stoppa World J Surg 1989; 13: % good results at 5.5 years Only 48% with good result if no mesh used Mortality rate 1.8% Sepsis Rate 12 % Conclusion: encourage experienced surgeons to use retro muscular prostheses to repair not only large but all incisional hernias Wantz SG & O Incisional Hernias with 3.8% recurrence

71 Rives Stoppa Repair

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79 The standard for location of mesh implantation for open ventral hernia repair is A. Superficial to the anterior rectus sheath with at least 4 cm overlap B. Between the anterior rectus sheath and the anterior rectus muscle with at least 4 cm overlap C. Sutured to the fascial edge of the defect D. Deep to the posterior rectus sheath/transversalis fascia with at least 4 cm overlap E. Mesh reinforcement of fascial margins with linear closure

80 The standard for location of mesh implantation for open ventral hernia repair is A. Superficial to the anterior rectus sheath with at least 4 cm overlap B. Between the anterior rectus sheath and the anterior rectus muscle with at least 4 cm overlap C. Sutured to the fascial edge of the defect D. Deep to the posterior rectus sheath/transversalis fascia with at least 4 cm overlap E. Mesh reinforcement of fascial margins with linear closure

81 In US Series: Recurrence rates % DeBord Hernia, 4 th ed, ed. Nyhus an dcondon Wantz SG&O 1991; 172(2): McLanahan Am J Surg 1997; 173 (5): American Hernia Society 1999 standard of care

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83 Component separation technique Method for abdominal wall reconstruction in pts with large midline hernias that cannot be closed primarily Used in contaminated situation when mesh should not be used 43 pts Mean f/u 15.5 months 32% recurrence rate De Vries et al, J Am Coll Surg 2003

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85 A 65 year old man is undergoing closure of a large abdominal hernia using component separation when the anesthesiologist notices that airway pressure has increased significantly. The most likely diagnosis is A. Right mainstem intubation B. Pulmonary edema C. Pneumothorax D. Pulmonary embolus E. Loss of domain

86 A 65 year old man is undergoing closure of a large abdominal hernia using component separation when the anesthesiologist notices that airway pressure has increased significantly. The most likely diagnosis is A. Right mainstem intubation B. Pulmonary edema C. Pneumothorax D. Pulmonary embolus E. Loss of domain

87 Seromas or ischemia can result from lateral dissection Secondary infection of seromas Pain from sutures, tension repair, large incisions Recurrence

88 When compared with open repair, laparoscopic ventral hernia repair has increased A. Postoperative complications B. Postoperative ileus C. Wound problems D. Length of stay E. Operative time

89 When compared with open repair, laparoscopic ventral hernia repair has increased A. Postoperative complications B. Postoperative ileus C. Wound problems D. Length of stay E. Operative time

90 Prior failed adequate laparoscopic ventral hernia repair. Prior skin graft over bowel Loss of abdominal domain Massive pannus, with simultaneous panniculectomy Active infection

91 Awad, et al. JACS 2005

92 Retrospective study of 850 consecutive LVHRs Complications 13.2 % Mean hospital stay 2.3 days Recurrence rate 4.7 % Most studies report outcomes of expert laparoscopic surgeons, with substantial experience in advanced and difficult cases Heniford, Park, Ramshaw, Voeller. Annals of Surgery, 2003

93 Mortality rates in literature: 0.6%, 1.1%, 3.1% and 3.4%. 18.5% of bowel injuries were not picked during the surgery. Bowel injury and mortality show a significant tendency to decrease < 1% after the surgeon s experience > 50 cases DA Moreno Egea et al Hernia (2004) 8:

94 # pts Technique Mean LOS Compl % Recurr Holzman 21/16 Varied 1.6/4.9 23/31 9.5/ Park 56/49 Tension free 3.4/6.5 18/37 11/ mesh Ramshaw 79/174 Varied 1.7/2.8 19/31 2.5/ Carbajo 30/30 Mesh 2.2/9.2 6/57 0/ Demaria 21/18 Mesh 0.8/4.4 19/50 0/ TOTAL AVG LAP OPEN

95 OPEN 2 50+% Recurrence 2 20% Wound Complications Longer LOS Slower Recovery LAPAROSCOPIC <5% Recurrence <2% Wound Complications Shorter LOS Quicker Recovery

96 Mesh repair with position behind the fascia (open or laparoscopic) leads to least recurrence Attention to technique principles and safety Quality training Better prospective studies are needed

97 BKP for all the technologic goodies and hernia expertise Drs Melvin, Marks, Rosen, Onders from who I borrowed anatomic and intraoperative images.

98 oclark Kensinger ocolleen Kiernan okristy Kummerow owilliam McMaster ofrank Stegall ojoshua Taylor omichael Vella

99 Erin Burke Atuhani Burnett Jash Datta Emma Hamilton Mohan Mallipeddi Alan Powers Ravi Rajaram Johanna Riesel Chris Scally Jonathan Scott Walter Wakwe Frank Zhao